ECG Guru - Instructor Resources - Right bundle branch block https://www.ecgguru.com/ecg/right-bundle-branch-block-1 en Right Bundle Branch Block https://www.ecgguru.com/blog/right-bundle-branch-block <div class="field field-name-field-blog-image field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/blog/right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/RBBB.jpg" width="3283" height="1392" alt="" /></a></div></div></div><div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>Why is this a right bundle branch block? We see a SR with broad QRS complexes (more than 120 ms). These are positive in the rightward leads III and especially in V1 and V2. In the more leftward leads I, aVL, V4-V6 there are clear S waves. This is a typical RBBB pattern.</p> </div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/119/feed" method="post" id="fivestar-custom-widget" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--2" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Right Bundle Branch Block 1/5</option><option value="40">Give Right Bundle Branch Block 2/5</option><option value="60">Give Right Bundle Branch Block 3/5</option><option value="80" selected="selected">Give Right Bundle Branch Block 4/5</option><option value="100">Give Right Bundle Branch Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.3</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-mFzuvIry7vfmsanaPcQLID8m8hoquuzG9strkwjbujY" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fblog%2Fright-bundle-branch-block&amp;title=Right%20%20Bundle%20%20Branch%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Tue, 24 Oct 2023 10:59:28 +0000 Dr A Röschl 875 at https://www.ecgguru.com https://www.ecgguru.com/blog/right-bundle-branch-block#comments Impending Trifascicular AV Block https://www.ecgguru.com/blog/impending-trifascicular-av-block <div class="field field-name-field-blog-image field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/blog/impending-trifascicular-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/impending.jpg" width="2578" height="1580" alt="" /></a></div></div></div><div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>Here we see the EKG of a 63-year-old man with CAD without relevant coronary stenosis. He complains of slightly reduced performance, but no other symptoms. The ECG shows the following changes:<br /> The rhythm is a sinus rhythm with positive P waves in the inferior leads and with a wide distance to the subsequent QRS complex, indicating a long PR interval (approximately 400 ms). The heart rate is 103 beats per minute, thus indicating sinus tachycardia. The P waves are difficult to recognize as they are only seen as small deflections on top of the T waves. In lead V1/V2 the typical pattern of a right bundle branch block is visible (rR' in V1 and V2). An over-rotated left axis type with continuous S waves up to V6 suggests a left anterior fascicular block. Therefore, a bifascicular block pattern is present. Additionally, there is this long AV block I. One can speak of an impending trifascicular block. A pacemaker indication does not arise solely from this EKG finding unless corresponding symptoms are present. Clinical follow-up examinations are of course necessary.</p> </div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/119/feed" method="post" id="fivestar-custom-widget--2" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--4" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Impending Trifascicular AV Block 1/5</option><option value="40">Give Impending Trifascicular AV Block 2/5</option><option value="60" selected="selected">Give Impending Trifascicular AV Block 3/5</option><option value="80">Give Impending Trifascicular AV Block 4/5</option><option value="100">Give Impending Trifascicular AV Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-km8HO4IUAq5HF6LZYWuPtglLilyfxamHv99w8UBi3ew" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fblog%2Fimpending-trifascicular-av-block&amp;title=Impending%20Trifascicular%20AV%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Mon, 28 Aug 2023 12:24:38 +0000 Dr A Röschl 867 at https://www.ecgguru.com https://www.ecgguru.com/blog/impending-trifascicular-av-block#comments Widespread ST Elevation With Right Bundle Branch Block https://www.ecgguru.com/ecg/widespread-st-elevation-right-bundle-branch-block <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/widespread-st-elevation-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/012423%20Inf%20Ant%20MI%20Rescue%201%20Edit%20GURU.jpg" width="1800" height="325" alt="" /></a></div><div class="field-item odd"><a href="/ecg/widespread-st-elevation-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/012423%20Inf%20Ant%20MI%20Rescue%202%20Edit%20Guru.jpg" width="1800" height="344" alt="" /></a></div><div class="field-item even"><a href="/ecg/widespread-st-elevation-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/012423%20Inf%20Ant%20MI%20ECG%203%20Hosp%201%20Edit%20GURU.jpg" width="1800" height="1393" alt="" /></a></div><div class="field-item odd"><a href="/ecg/widespread-st-elevation-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/012423%20Inf%20Ant%20MI%20Hosp%202%20ECG%204%20Edit.jpg" width="1800" height="1384" alt="" /></a></div><div class="field-item even"><a href="/ecg/widespread-st-elevation-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/012423%20Inf%20Ant%20MI%20Hosp%203%20ECG%205%20Rt%20Precord%20Edit%20GURU.jpg" width="1800" height="1356" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left">Usually, instructors of basic ECG classes look for examples of the most common conditions that are likely to be encountered by the learners.<span style="mso-spacerun: yes;">&nbsp; </span>But, sometimes, it is advantageous to show students more unusual presentations to remind them of the infinite possibilities when we care for living beings.<span style="mso-spacerun: yes;">&nbsp; </span>This series is a very good example of what can and does happen to some people with cardiovascular disease.<span style="mso-spacerun: yes;">&nbsp; </span>It will give your students an opportunity to think about possible interpretations, and also about anticipating clinical implications and emergencies that may arise.<strong></strong></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The Patient:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span>This patient is a man in his 80s who has been active his whole life.<span style="mso-spacerun: yes;">&nbsp; </span>He considers himself to be healthy, giving no medical history and denying medication use. He states that he has had a yearly health exam.<span style="mso-spacerun: yes;">&nbsp; </span>Today, he felt “tired and dizzy” while raking leaves.<span style="mso-spacerun: yes;">&nbsp; </span>As he walked to his house to rest, he had a syncopal episode and fell, hitting his head. He was unconscious for a few minutes. A family member called for Emergency Medical Services (EMS). Paramedics found him awake and complaining of bilateral “shoulder and wrist” pain. He had no obvious trauma to his extremities, but had some bruising on his head and face.<span style="mso-spacerun: yes;">&nbsp; </span>He denied recent illness and substance abuse.<span style="mso-spacerun: yes;">&nbsp; </span>He was oriented x3. He was pale and diaphoretic, and complained of nausea. He denied chest or back pain.<span style="mso-spacerun: yes;">&nbsp; </span>He denied shortness of breath.<span style="mso-spacerun: yes;">&nbsp; </span>BP 100/60.<span style="mso-spacerun: yes;">&nbsp; </span>Heart rate bradycardic.<span style="mso-spacerun: yes;">&nbsp; </span>SPO2 above 95%.<span style="mso-spacerun: yes;">&nbsp; </span>He was given aspirin and ondasetron, and transported to a hospital.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The first ECG</span></strong>was taken on arrival of the paramedics.<span style="mso-spacerun: yes;">&nbsp; </span>We see:<span style="mso-spacerun: yes;">&nbsp; </span><strong>sinus bradycardia</strong> at 42 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>The PR interval is normal at 180 ms.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS duration is 158 ms and there is <strong>right bundle branch block</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>The <strong>frontal plane axis is normal</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>The <strong>inferior wall leads</strong>, II, III, and aVF have marked ST elevation, along with T wave inversion.<span style="mso-spacerun: yes;">&nbsp; </span>The ST elevation is due to transmural ischemia (STEMI).<span style="mso-spacerun: yes;">&nbsp; </span>This finding is backed up by the ST depression in I and aVL.<span style="mso-spacerun: yes;">&nbsp; </span>Reciprocal ST depression confirms that the STE in the inferior leads is due to M.I.</p><p class="MsoNormal" style="text-align: left;" align="left">Another unwelcome finding is in the precordial leads.<span style="mso-spacerun: yes;">&nbsp; </span>V<sub>1</sub> has a small ST elevation, plus a straight ST segment and flat T wave.<span style="mso-spacerun: yes;">&nbsp; </span>V<sub>2</sub> through V<sub>5</sub> have very pronounced ST elevation with a straight shape, and V<sub>6</sub> has a more subtle version of the same thing.<span style="mso-spacerun: yes;">&nbsp; </span>So, this looks like an acute coronary event happening simultaneously in the inferior and anterior walls!</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The second ECG</span></strong>was taken enroute to the hospital. According to the paramedics, the electrodes were not changed, and the patient’s position was not changed drastically.<span style="mso-spacerun: yes;">&nbsp; </span>Now, we see a heartrate of 51 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>Still slow, but slightly better. The inferior leads now have no STE, although the shape of the ST segment is flat and straight (not good).<span style="mso-spacerun: yes;">&nbsp; </span>We also do not see reciprocal STD in I and aVL.<span style="mso-spacerun: yes;">&nbsp; </span>Could this be a return of blood flow to the inferior wall?<span style="mso-spacerun: yes;">&nbsp; </span>Or an electrode position or patient position issue? The frontal plane axis has shifted to the left. Again, position, or onset of left anterior hemiblock? There is still STE in V<sub>1</sub>, V<sub>2</sub>, and V<sub>3</sub>, although the lateral chest leads look improved.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The third ECG</span></strong>was taken in the hospital, upon arrival of the patient.<span style="mso-spacerun: yes;">&nbsp; </span>The rate is 48 bpm, and we still see sinus bradycardia with RBBB.<span style="mso-spacerun: yes;">&nbsp; </span>This ECG looks very similar to the second field ECG.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The fourth ECG</span></strong>was taken ten minutes after the third. Now, we see a return to STEMI patterns in both inferior and anterior walls. Leads II, III, and aVF show us blatant STE, with corroborating reciprocal ST depression in I and aVL.<span style="mso-spacerun: yes;">&nbsp; </span>There is even reciprocal depression in V<sub>1</sub> and V<sub>2</sub>, a common finding in inferior wall MI, indicating extension of the transmural injury up the posterior wall.<span style="mso-spacerun: yes;">&nbsp; </span>In the first field ECG, this sign was obliterated by the STE in those leads.<span style="mso-spacerun: yes;">&nbsp; </span>There is STE in V<sub>3</sub>- V<sub>5</sub>, with ST flattening in V<sub>6</sub>.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The fifth ECG</span></strong>was taken with the chest leads placed on the right side of the chest.<span style="mso-spacerun: yes;">&nbsp; </span>That is, V<sub>1</sub> and V<sub>2</sub> wires were switched, and V<sub>3 </sub>through V<sub>6</sub> are in the usual anatomical positions, except on the patient’s right chest.<span style="mso-spacerun: yes;">&nbsp; </span>We now see marked STE in V<sub>3</sub>Rt through V<sub>6</sub>Rt.<span style="mso-spacerun: yes;">&nbsp; </span><strong>Right ventricular MI.</strong><strong><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></strong></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">What do you make of all of this?</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span>There are several options, even after ruling out electrode placement issues.<span style="mso-spacerun: yes;">&nbsp; </span>The patient has remained awake and alert, although bradycardic and symptomatic. The answers will lie in the findings in the cath lab.<span style="mso-spacerun: yes;">&nbsp; </span>If the patient has typical coronary artery anatomy and distribution, I would guess that these ECGs represent severe triple vessel disease, with some lesions that are not 100% occlusive.<span style="mso-spacerun: yes;">&nbsp; </span>That is, as the arteries dilate, blood flow would improve – when they constrict, blood flow would be affected, and the ECG would reflect this perfusion change.<span style="mso-spacerun: yes;">&nbsp; </span>There are many possibilities other than this to consider: “Type 2 M.I”, which is ischemia due to an overall perfusion drop due to a medical or trauma condition; coronary artery spasm; or unusual configuration of the coronary arteries. Occasionally, angiograms reveal an extremely dominant artery that is responsible for most of the heart. There may be a “wrap around” LAD, which wraps around the apex of the left ventricle, perfusing the inferior wall along with the anterior wall.<span style="mso-spacerun: yes;">&nbsp; </span>There are even instances of only one coronary artery arising from the aorta, with the other being a branch of the first. So there might be only one branch from the aorta.<span style="mso-spacerun: yes;">&nbsp; </span>For example, the LCA might be the only coronary artery branching off the aorta, with the RCA being a branch off the LCA.<span style="mso-spacerun: yes;">&nbsp; </span>A proximal lesion would affect all parts of the heart.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">Patient follow up:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span>The patient had a cardiac cath.<span style="mso-spacerun: yes;">&nbsp; </span>He was found to have severe multi-vessle disease with the following lesions:<span style="mso-spacerun: yes;">&nbsp; </span>Right coronary artery, 99% occlusive lesion. Proximal left coronary artery, 40% lesion.<span style="mso-spacerun: yes;">&nbsp; </span>Left anterior descending coronary artery, 75% lesion.<span style="mso-spacerun: yes;">&nbsp; </span>He was successfully cardioverted from ventricular tachycardia once, and was placed on a balloon pump (we do not know his EF at the time of the cath).<span style="mso-spacerun: yes;">&nbsp; </span>He declined CABG surgery, and was evaluated for possible percutaneous intervention. We do not have further information.</p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;</p><p class="MsoNormal" style="text-align: left;" align="left"><em><span style="font-size: 9.0pt; line-height: 107%; color: #385623; mso-themecolor: accent6; mso-themeshade: 128;">Our thanks to Timothy Chopelas for donating this case.</span></em></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/119/feed" method="post" id="fivestar-custom-widget--3" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--6" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Widespread ST Elevation With Right Bundle Branch Block 1/5</option><option value="40">Give Widespread ST Elevation With Right Bundle Branch Block 2/5</option><option value="60">Give Widespread ST Elevation With Right Bundle Branch Block 3/5</option><option value="80" selected="selected">Give Widespread ST Elevation With Right Bundle Branch Block 4/5</option><option value="100">Give Widespread ST Elevation With Right Bundle Branch Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.7</span></span> <span class="total-votes">(<span >10</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-M4Tix2U7DRQvikwjEvlov64vW0zHwpI6VvqQVVRU7sc" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item odd"><a href="/ecg/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item even"><a href="/ecg/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item odd"><a href="/ecg/posterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Posterior M.I.</a></div><div class="field-item even"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fwidespread-st-elevation-right-bundle-branch-block&amp;title=Widespread%20ST%20Elevation%20With%20Right%20Bundle%20Branch%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 04 Feb 2023 16:22:21 +0000 Dawn 836 at https://www.ecgguru.com https://www.ecgguru.com/ecg/widespread-st-elevation-right-bundle-branch-block#comments Marked Bradycardia With Bifascicular Block https://www.ecgguru.com/ecg/marked-bradycardia-bifascicular-block <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/marked-bradycardia-bifascicular-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Junctional%20RBBB%20LPH.jpg" width="1800" height="1257" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp; </span></span><span style="font-size: 12.0pt; line-height: 107%;">This ECG was taken from an elderly woman. Unfortunately, we do not know any details about the case.<span style="mso-spacerun: yes;">&nbsp; </span>That acknowledged, there are many interesting aspects to this ECG.</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The ECG:</span></strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 12.0pt; line-height: 107%;">The first thing we notice is the severe <strong>bradycardia</strong> – almost certain to be symptomatic.<span style="mso-spacerun: yes;">&nbsp; </span>The rate is 32 bpm and the rhythm is regular.<span style="mso-spacerun: yes;">&nbsp; </span>There are no P waves.<span style="mso-spacerun: yes;">&nbsp; </span>This is a <strong>junctional rhythm</strong>, slightly slower than expected from junctional escape.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The QRS shows the presence of <strong>right bundle branch block</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>Each QRS on the ECG starts as a narrow complex, but then adds an “extra” wave onto the end – the delay caused by the right ventricle depolarizing late.<span style="mso-spacerun: yes;">&nbsp; </span>The terminal delay is very noticeable in V1 as an R’ wave, and in Leads I and V6 as a small, wide s wave.<span style="mso-spacerun: yes;">&nbsp; </span>There is right axis deviation, so the diagnosis of <strong>bifascicular block</strong> (RBBB and left posterior fascicular block) can be made.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">V2 through V6 show <strong>fragmentation of the QRS </strong>complexes and a loss of voltage and R wave progression.<span style="mso-spacerun: yes;">&nbsp; </span>This points to anterior wall M.I. We can’t know the age of the M.I. without clinical correlation, but the ST segments in those leads are very <strong>flat,</strong> with uniformly symmetrical <strong>inverted T waves</strong> all the way to V6.<span style="mso-spacerun: yes;">&nbsp; </span>All of these signs indicate recent injury.<span style="mso-spacerun: yes;">&nbsp; </span>An anterior M.I. can cause the bifascicular block we are seeing, since the bundle branches begin in the septum.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Our patient has a host of <strong>conduction system problems</strong>:<span style="mso-spacerun: yes;">&nbsp; </span>there is no sign of sinus node activity, the junctional escape rhythm is slow even for the junction, there is a right bundle branch block, and the left posterior fascicle is blocked. <span style="mso-spacerun: yes;">&nbsp;</span>Many diseases can cause these conduction system failures, including M.I. as well as diseases causing inflammation and fibrosis of tissues. Finding the underlying cause(s) of all these abnormalities is very important, but the FIRST consideration should be protecting perfusion by insuring an adequate rate.<span style="mso-spacerun: yes;">&nbsp; </span>This patient is certainly a candidate for a pacemaker, with her bradycardia and the fact that she is living with only one main fascicle in her bundle branches (the anterior-superior fascicle).</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/119/feed" method="post" id="fivestar-custom-widget--4" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--8" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Marked Bradycardia With Bifascicular Block 1/5</option><option value="40">Give Marked Bradycardia With Bifascicular Block 2/5</option><option value="60">Give Marked Bradycardia With Bifascicular Block 3/5</option><option value="80" selected="selected">Give Marked Bradycardia With Bifascicular Block 4/5</option><option value="100">Give Marked Bradycardia With Bifascicular Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.4</span></span> <span class="total-votes">(<span >78</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-ebAsmiwLzp1fo9T2zd7fAMmTEyFar8kO0AEX3l81N10" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/bifascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bifascicular block</a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item even"><a href="/ecg/left-posterior-fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior fascicular block</a></div><div class="field-item odd"><a href="/ecg/left-posterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior hemiblock</a></div><div class="field-item even"><a href="/ecg/junctional-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional rhythm</a></div><div class="field-item odd"><a href="/ecg/qrs-fragmentation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">QRS fragmentation</a></div><div class="field-item even"><a href="/ecg/st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST changes</a></div><div class="field-item odd"><a href="/ecg/anterior-wall-mi-5" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior wall M.I.</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_4"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fmarked-bradycardia-bifascicular-block&amp;title=Marked%20Bradycardia%20With%20Bifascicular%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 10 Jul 2022 20:08:14 +0000 Dawn 817 at https://www.ecgguru.com https://www.ecgguru.com/ecg/marked-bradycardia-bifascicular-block#comments Wide Complex Tachycardia https://www.ecgguru.com/ecg/wide-complex-tachycardia-5 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/wide-complex-tachycardia-5"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/18-18%20Edited.jpg" width="1800" height="646" alt="" /></a></div><div class="field-item odd"><a href="/ecg/wide-complex-tachycardia-5"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/18-31%20%20%20Edited.jpg" width="1800" height="652" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><span style="font-size: 14.0pt;">This pair of ECGs feature one of our recurring themes:<span style="mso-spacerun: yes;">&nbsp; </span>wide-complex tachycardia (WCT). It is a fascinating topic, as tachycardia has many causes and many mechanisms, and wide QRS also has many causes, with the mechanism being slow conduction through the ventricles.</span><span style="font-size: 14pt;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><span style="font-size: 14.0pt;">Sometimes, it is not possible to diagnose the true origin of a WCT from one ECG, or even serial ECGs.<span style="mso-spacerun: yes;">&nbsp; </span>Is the tachycardia due to increased sympathetic activity (fear, dehydration, exercise, hypoxia, hypovolemia, etc.)?<span style="mso-spacerun: yes;">&nbsp; </span>Or is the fast rate due to reentry, where one impulse gets “caught” in a loop, repeating itself rapidly, and depolarizing the myocardium with each pass?<span style="mso-spacerun: yes;">&nbsp; </span>What is the location of the pacemaker that is responsible for the rhythm?<span style="mso-spacerun: yes;">&nbsp; </span>Is it a supraventricular rhythm that has suffered an intraventricular conduction delay, widening the QRS?<span style="mso-spacerun: yes;">&nbsp; </span>Or is the rhythm originating in a ventricular pacemaker, without the ability to travel on the fast highway that is the intraventricular conduction system?</span><span style="font-size: 14pt;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><span style="font-size: 14.0pt;">If you or your students work in an acute care setting, such as pre-hospital or emergency department, you may not be with the patient long enough or be able to conduct enough tests to determine without a doubt the answers to the above questions.<span style="mso-spacerun: yes;">&nbsp; </span>Some WCTs cause such severe symptoms that they must be dealt with quickly, to avoid rapid deterioration to ventricular fibrillation.<span style="mso-spacerun: yes;">&nbsp; </span>For that reason, there is a widely-accepted rule for WTC treatment:</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><strong><span style="font-size: 14.0pt; color: #c00000;">TREAT ALL WIDE-COMPLEX TACHYCARDIA AS IF IT IS V TACH UNTIL PROVEN OTHERWISE. <span style="mso-spacerun: yes;">&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span></span></strong><strong><span style="font-size: 14.0pt; color: #c00000;">&nbsp;</span></strong></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><strong><span style="font-size: 14.0pt; color: #00b050;">The Patient:</span></strong><span style="font-size: 14.0pt; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 14.0pt;">These two tracings were taken from an elderly man who complained of feeling sick. He was found by paramedics to be alert, diaphoretic, tachypneic, and complaining of palpitations. His initial vital signs were:<span style="mso-spacerun: yes;">&nbsp; </span>BP 80/60, Pulse 167 and regular, respirations 30/min. Pulse oximetry 96%.</span><span style="font-size: 14pt;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><strong><span style="font-size: 14.0pt; color: #00b050;">ECG No. 1 at 18:18:44<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="font-size: 14.0pt;">The rhythm is regular at 167/min.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS width is about .12 seconds (120 ms). It is difficult to measure the QRS width with precision due to artifact and slurred terminal portions of most of the QRS complexes. No clear P waves are seen, possibly due to the rate causing P-on-T.<span style="mso-spacerun: yes;">&nbsp; </span>Several features of the QRS morphology suggest VENTRICULAR TACHYCARDIA, including the extreme axis (almost vertical), and the negative deflection in Lead V6. When V tach has this pattern: <span style="mso-spacerun: yes;">&nbsp;</span>a minimally-wide QRS with a right bundle branch block pattern, it is usually “fascicular ventricular tachycardia”.</span><span style="font-size: 14pt;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><strong><span style="font-size: 14.0pt; color: #00b050;">Initial Treatment:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="font-size: 14.0pt;">Because of the patient’s hemodynamic instability and symptoms, the EMS crew elected to follow the above rule and treat this rhythm as VENTRICULAR TACHYCARDIA.<span style="mso-spacerun: yes;">&nbsp; </span>He was administered Amiodarone 150 mg IV while the crew prepared to cardiovert him under light sedation.<span style="mso-spacerun: yes;">&nbsp; </span>As soon as they were able, he was cardioverted with 120 j.<span style="mso-spacerun: yes;">&nbsp; </span>The new rhythm is shown in ECG #2.</span><span style="font-size: 14pt;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><strong><span style="font-size: 14.0pt; color: #00b050;">ECG No. 2 at 18:31:55 <span style="mso-spacerun: yes;">&nbsp;</span></span></strong><span style="font-size: 14.0pt;">The patient’s rhythm remains regular at about 130 / min.&nbsp;</span><span style="font-size: 14pt;">Respiratory rate 20/min. and unlabored.</span><span style="font-size: 14pt;">&nbsp; </span><span style="font-size: 14pt;">BP 92/58.</span><span style="font-size: 14pt;">&nbsp; </span><span style="font-size: 14pt;">Pulse ox: 97% on nasal O2.</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><span style="font-size: 14.0pt;">The most interesting finding is the QRS morphology has not changed.<span style="mso-spacerun: yes;">&nbsp; </span>The width is still .12 sec., and the axis and other features of the QRS complexes are the same as they were in the faster rhythm.<span style="mso-spacerun: yes;">&nbsp; </span>In addition, in spite of the artifact, I feel that P waves are present.<span style="mso-spacerun: yes;">&nbsp; </span>A cleaner ECG might prove it, but I am confident of the P waves in Leads II, III and V3.<span style="mso-spacerun: yes;">&nbsp; </span>I will readily admit that a clear, artifact-free ECG might prove me wrong.<span style="mso-spacerun: yes;">&nbsp; </span>If this is SINUS TACHYCARDIA, the first ECG was most certainly not V Tach, because the QRS complexes haven’t changed.<span style="mso-spacerun: yes;">&nbsp; </span>If we accept that there are P waves, the first rhythm was paroxysmal supraventricular tachycardia.<span style="mso-spacerun: yes;">&nbsp; </span>The wide complexes would be due to right bundle branch block and anterior superior fascicular block (also called hemiblock).<span style="mso-spacerun: yes;">&nbsp; </span>The RBBB causes rSR’ pattern in V1 and wide S waves in I and V6, and explains the slightly widened QRS.</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><span style="font-size: 14.0pt;">The fascicular block causes the extreme left axis shift.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><span style="font-size: 14.0pt;">If you don’t see P waves, then we would have to explain how the cardioversion changed the rhythm from a “fast V Tach” to a “slow V Tach.”</span><span style="font-size: 14pt;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><strong><span style="font-size: 14.0pt; color: #00b050;">Patient Outcome:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="font-size: 14.0pt;">The crew, by treating this WCT as V tach, obtained a quick improvement in the rate, which helped with the symptoms.<span style="mso-spacerun: yes;">&nbsp; </span>Amiodarone and cardioversion are both appropriate treatments for V tach and PSVT.</span><span style="font-size: 14pt;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><span style="font-size: 14.0pt;">The patient was diagnosed at the hospital with “arrhythmia due to an infection, combined with effects of a weight-loss medication”.<span style="mso-spacerun: yes;">&nbsp; </span>He had a cardiac catheterization which was negative for significant coronary artery disease. We have no information on the diagnosis of the arrhythmia, or what his ECG looked like on discharge, one week later.</span><span style="font-size: 14pt;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><strong><span style="font-size: 14.0pt; color: #00b050;">As always, we welcome your comments and opinions on this case.</span></strong><span style="font-size: 14pt;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"><em><span style="font-size: 9.0pt;">Many thanks to Lt. Curtis Jepsen for donating these tracings. </span></em></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/119/feed" method="post" id="fivestar-custom-widget--5" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--10" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Wide Complex Tachycardia 1/5</option><option value="40">Give Wide Complex Tachycardia 2/5</option><option value="60">Give Wide Complex Tachycardia 3/5</option><option value="80" selected="selected">Give Wide Complex Tachycardia 4/5</option><option value="100">Give Wide Complex Tachycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.3</span></span> <span class="total-votes">(<span >100</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--5" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-2dlqZUEr7Dm72DilSt26hw3zdXZgp0qcAFnbzRYFIA0" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/wide-complex-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide complex tachycardia</a></div><div class="field-item odd"><a href="/ecg/wide-qrs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide QRS</a></div><div class="field-item even"><a href="/ecg/ventricular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular tachycardia</a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item even"><a href="/ecg/left-anterior-fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior fascicular block</a></div><div class="field-item odd"><a href="/ecg/left-anterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior hemiblock</a></div><div class="field-item even"><a href="/ecg/fascicular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Fascicular tachycardia</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_5"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fwide-complex-tachycardia-5&amp;title=%20Wide%20Complex%20Tachycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 06 Feb 2021 03:11:12 +0000 Dawn 797 at https://www.ecgguru.com https://www.ecgguru.com/ecg/wide-complex-tachycardia-5#comments Second-degree AV Block, Type II https://www.ecgguru.com/ecg/second-degree-av-block-type-ii-1 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/second-degree-av-block-type-ii-1"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB122%20%202nd%20deg%20Type%20II%203%20to%201.jpg" width="1887" height="1454" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong><span style="color: #00b050;">The patient:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span>Unfortunately, we no longer have information on this patient, other than the fact that she went to the OR for a permanent pacemaker implantation.</p><p class="MsoNormal"><strong><span style="color: #00b050;">The ECG:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span>The atrial rate (P waves) is 99 beats per minute. The P waves are regular and all alike (NSR). The ventricular rate (QRS complexes) is 33 bpm, and the QRS complexes are regular and all alike. The PR intervals, when A-V conduction occurs, are 162 ms (.16 seconds) and all alike. The QRS complexes are wide, at 122 ms (.12 seconds). There is <strong>right bundle branch block</strong>, but no left hemiblock, as the frontal plane axis is normal. The QTc is prolonged at 549 ms.<span style="mso-spacerun: yes;">&nbsp; </span>Many ST segments on this ECG have a “flat” appearance, rather than the normal concave up shape.</p><p class="MsoNormal">The failure of 2 out of every 3 P waves to conduct indicates a <strong>second-degree AV block. </strong>Type I is a block of the AV node, with progressive prolongation of the PR interval until ONE P wave fails to conduct. Type II AV block is a block of the intraventricular conduction system. Clues that a second-degree AV block is Type II include:</p><p class="MsoListParagraphCxSpFirst" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->The PR intervals are all alike.</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->More than one consecutive P wave is not conducted.</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->A P wave that is NOT in the refractory period of the preceding beat is not conducted.</p><p class="MsoListParagraphCxSpLast" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->There is evidence of bundle branch (fascicular) block.</p><p class="MsoNormal">This is a <strong>second-degree AV block, Type II.</strong><span style="mso-spacerun: yes;">&nbsp; </span>Type II blocks are considered to be <em>intermittent tri-fascicular blocks.</em><span style="mso-spacerun: yes;">&nbsp; </span>That is, one or two of the three main fascicles are blocked, and the remaining one or two are intermittently blocked.<span style="mso-spacerun: yes;">&nbsp; </span>When conduction proceeds down the working fascicle(s), there is a QRS complex. When the intermittent block occurs, all three fascicles are blocked, producing a temporary complete heart block (trifascicular block).<span style="mso-spacerun: yes;">&nbsp; </span>In this example, it appears that the right bundle branch (one fascicle) is consistently blocked, and the left bundle branch (two fascicles) is intermittently blocked.</p><p class="MsoNormal">The most immediate concern for any patient with an AV block is <strong>rate</strong>. It is important to assess the patient’s perfusion status to determine if the rate is fast enough to maintain BP.<span style="mso-spacerun: yes;">&nbsp; </span>Type I AV blocks often respond to atropine, but Type II AV blocks do not, and it may even make them worse.<span style="mso-spacerun: yes;">&nbsp; </span>The safest approach is a <strong>temporary pacemaker</strong>, either transcutaneous or transvenous, to stabilize the patient. Type II AV blocks usually require a permanent implanted pacemaker, as they tend to worsen and lead to third-degree AV block with ventricular escape (rate &lt; 40 bpm) or ventricular standstill.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/119/feed" method="post" id="fivestar-custom-widget--6" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--12" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Second-degree AV Block, Type II 1/5</option><option value="40">Give Second-degree AV Block, Type II 2/5</option><option value="60">Give Second-degree AV Block, Type II 3/5</option><option value="80" selected="selected">Give Second-degree AV Block, Type II 4/5</option><option value="100">Give Second-degree AV Block, Type II 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.1</span></span> <span class="total-votes">(<span >50</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--6" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-C_UaiWu-wTZ-91KHRlU2r5ZBOkj94i-c92XW6eGEl0Q" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/second-degree-av-block-type-ii" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Second-degree AV block Type II</a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item even"><a href="/ecg/av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AV Block</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_6"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fsecond-degree-av-block-type-ii-1&amp;title=Second-degree%20AV%20Block%2C%20Type%20II%20"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 08 Dec 2020 19:47:50 +0000 Dawn 793 at https://www.ecgguru.com https://www.ecgguru.com/ecg/second-degree-av-block-type-ii-1#comments Right Bundle Branch Block and More https://www.ecgguru.com/ecg/right-bundle-branch-block-and-more <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/right-bundle-branch-block-and-more"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/SR%20w%20PACs%2011.43.jpg" width="1800" height="663" alt="" /></a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-and-more"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Leads%2013%2C%2014%2C%2015_0.jpg" width="1800" height="689" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-tab-count: 1;">&nbsp;&nbsp;&nbsp; </span>These tracings are taken from a 75-year-old man who became weak while playing golf on a very hot day.<span style="mso-spacerun: yes;">&nbsp; </span>He was pale and diaphoretic.<span style="mso-spacerun: yes;">&nbsp; </span>He was hypotensive, but we do not know his BP reading. He denies chest pain or discomfort. The patient reported a history of lung cancer and hypertension. We have no other history, and unfortunately, no follow-up information.</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">ECG Number 1: </span></strong><strong><span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-tab-count: 1;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></strong><span style="font-size: 12.0pt; line-height: 107%;">The first ECG shows the standard 12 leads.<span style="mso-spacerun: yes;">&nbsp; </span>The rhythm is sinus with frequent appearances of PAC couplets.<span style="mso-spacerun: yes;">&nbsp; </span>The sinus rate varies slightly from about 76 bpm to 68 bpm, tending to slow a bit after the premature atrial contractions.<span style="mso-spacerun: yes;">&nbsp; </span>There is a right bundle branch block, and the QRS duration is about .12 seconds (120 ms). The PR interval is slightly log at 223 ms.<span style="mso-spacerun: yes;">&nbsp; </span>We do not know what medications the patient is on, and we do not have an older ECG for comparison.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">There are some interesting, if subtle, changes worth mentioning.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS complexes in most leads are fragmented.<span style="mso-spacerun: yes;">&nbsp; </span>That is, they have notching in the terminal S or R waves that is not due to the bundle branch block. This can be a sign of scarring, and can also be considered an equivalent to a pathological Q wave.<span style="mso-spacerun: yes;">&nbsp; </span>Speaking of pathological Q waves, they are seen in the inferior leads, II, III, and aVF.<span style="mso-spacerun: yes;">&nbsp; </span>There are also prominent, though not large Q waves in V4 through V6, leads which normally do not have them. All this points to scarring and possibly long-term coronary artery disease, with possible old M.I.<span style="mso-spacerun: yes;">&nbsp; </span>In addition, the ST segments are not entirely normal.<span style="mso-spacerun: yes;">&nbsp; </span>There is ST depression in the inferior and low lateral leads, a little ST elevation in aVL.<span style="mso-spacerun: yes;">&nbsp; </span>Also, the SHAPES of the ST segments tend to be straight throughout the ECG, instead of the usual curved (concave up) appearance. </span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">ECG Number 2:<span style="mso-tab-count: 1;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">The second ECG was obtained with three additional leads, to search for ST elevation that might have been missed by the standard 12 leads.<span style="mso-spacerun: yes;">&nbsp; </span>V4, Right has been added in place of V4.<span style="mso-spacerun: yes;">&nbsp; </span>V8 and V9 have been added to the V5 and V6 positions on the print out.<span style="mso-spacerun: yes;">&nbsp; </span>V4R shows us a pathological Q wave and fragmentation.<span style="mso-spacerun: yes;">&nbsp; </span>The posterior leads do, too, and the ST segments are very flat and slightly elevated.</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">Conclusion: <span style="mso-spacerun: yes;">&nbsp;</span></span></strong><span style="font-size: 12.0pt; line-height: 107%;">Without further evaluation of the patient, and comparison with previous ECGs, it would be very difficult to assign significance to these changes.<span style="mso-spacerun: yes;">&nbsp; </span>Because of his symptoms, he was transported by EMS to a hospital.<span style="mso-spacerun: yes;">&nbsp; </span>For teachers, this is a good example of PAC couplets for your beginner students, and a chance to discuss QRS fragmentation, pathological Q waves, and ST segment shape with your more advanced students.<span style="mso-spacerun: yes;">&nbsp; </span>Also, the value of additional leads to rule out ST elevation M.I. should be emphasized.</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/119/feed" method="post" id="fivestar-custom-widget--7" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--14" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Right Bundle Branch Block and More 1/5</option><option value="40">Give Right Bundle Branch Block and More 2/5</option><option value="60">Give Right Bundle Branch Block and More 3/5</option><option value="80" selected="selected">Give Right Bundle Branch Block and More 4/5</option><option value="100">Give Right Bundle Branch Block and More 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.4</span></span> <span class="total-votes">(<span >43</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--7" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-jXIMUS6t1dINCSLXfXw0xwV9AFxsZGHfIufA4ojZ_xg" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item odd"><a href="/ecg/rbbb" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">RBBB</a></div><div class="field-item even"><a href="/ecg/left-posterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior hemiblock</a></div><div class="field-item odd"><a href="/ecg/qrs-fragmentation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">QRS fragmentation</a></div><div class="field-item even"><a href="/ecg/pacs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PACs</a></div><div class="field-item odd"><a href="/ecg/couplets" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Couplets</a></div><div class="field-item even"><a href="/ecg/st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST changes</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_7"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fright-bundle-branch-block-and-more&amp;title=%20Right%20Bundle%20Branch%20Block%20and%20More"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 22 Aug 2020 21:33:52 +0000 Dawn 788 at https://www.ecgguru.com https://www.ecgguru.com/ecg/right-bundle-branch-block-and-more#comments High-grade AV Block With Profound Bradycardia https://www.ecgguru.com/ecg/high-grade-av-block-profound-bradycardia <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/high-grade-av-block-profound-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB120%20High%20grade%20w%20sinus%20brady.jpg" width="1800" height="768" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal">If you are an ECG instructor, you probably carefully choose ECGs to illustrate the topic you are teaching. One of the reasons for the existence of the ECG Guru website is our desire to provide lots of such illustrations for you to choose from.</p><p class="MsoNormal">Sometimes, though, an ECG does not clearly illustrate one specific dysrhythmia well, because the interpretation of the ECG depends on so many other factors.<span style="mso-spacerun: yes;">&nbsp; </span>In order to get it “right”, we would need to know information about the patient’s history, presentation, lab results, or previous ECGs. We might need to see the ECG done immediately before or after the one we are looking at.<span style="mso-spacerun: yes;">&nbsp; </span>Some ECG findings must ultimately be confirmed by an electrophysiology study before we can know for sure what is going on.</p><p class="MsoNormal">For those of us who are “ECG nerds”, it can be fun to debate our opinions and even more fun to hear from wiser, more advanced practitioners about their interpretations.</p><p class="MsoNormal">My belief, as a clinical instructor, is that we must teach strategies for treating the patient who has a “controversial” ECG that take into account the level of the practitioner, the care setting, and the patient’s hemodynamic status.<span style="mso-spacerun: yes;">&nbsp; </span>In some settings, it might be absolutely forbidden for a first-responder to cardiovert atrial fibrillation, for example.<span style="mso-spacerun: yes;">&nbsp; </span>But atrial fib is routinely cardioverted under controlled conditions in hospitals.<span style="mso-spacerun: yes;">&nbsp; </span>The general rule followed by emergency providers that “all wide-complex tachycardias are v tach until proven otherwise” has no doubt prevented deaths in situations where care providers did not agree on the origin of the tachycardia.</p><p class="MsoNormal"><strong><span style="color: #00b050;">The ECG: <span style="mso-spacerun: yes;">&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span></span></strong>We do not have much patient information to go with this ECG, just that it is from a 71-year-old woman who developed severe hypotension and lost consciousness, but was revived with transcutaneous pacing.<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>Here is what we do know about this ECG:</p><p class="MsoListParagraphCxSpFirst" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->There are regular P waves, at a rate of about 39 bpm (sinus bradycardia).</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->There are only two QRS complexes, shown in a total of six leads, and the rate is 13 bpm.</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->The two PR intervals that are seen are the same at 368 ms, or .368 seconds (first-degree AVB).</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->There are three P waves for every QRS complex. (second-degree AVB, Type II).</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->The QRS complexes are 144 ms wide (.14 seconds).</p><p class="MsoListParagraphCxSpLast" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->The QRS morphology cannot be evaluated in 12 leads here, but the pattern is consistent with right bundle branch block and left anterior fascicular block (bifascicular block).<span style="mso-spacerun: yes;">&nbsp; </span>Were we at the bedside, another 10 seconds of 12-lead ECG might produce a QRS that falls into the remaining leads’ sections of the tracing.</p><p class="MsoNormal">It would be very important to determine what caused the severe slowing of conduction. The paper speed has not been altered, and that should be ruled out whenever all rates and intervals are prolonged.<span style="mso-spacerun: yes;">&nbsp; </span>The severe sinus bradycardia, second-degree AVB, first-degree AVB, and bundle branch block all point to a global cause of poor conduction.<span style="mso-spacerun: yes;">&nbsp; </span>Electrolytes, drugs, vagal stimulation, possible acute M.I. – all of these need to be assessed.<span style="mso-spacerun: yes;">&nbsp; </span>And, eventually, the best definitive treatment will need to be decided.</p><p class="MsoNormal">But what is the <strong>MOST IMPORTANT </strong>issue here?<span style="mso-spacerun: yes;">&nbsp; </span><strong><span style="color: #c00000;">The RATE!</span></strong><span style="color: #c00000;"><span style="mso-spacerun: yes;">&nbsp; </span></span>And the patient’s response to the extremely slow rate.<span style="mso-spacerun: yes;">&nbsp; </span>Before we spend any time on the cause or treatment, we must address the rate and the patient’s hemodynamic status.<span style="mso-spacerun: yes;">&nbsp; </span>A transcutaneous pacemaker, if available, is called for.<span style="mso-spacerun: yes;">&nbsp; </span>CPR may be needed until the pacemaker can provide a perfusing rate. Rate-enhancing drugs may be used, and temporary transvenous pacing.<span style="mso-spacerun: yes;">&nbsp; </span>If the patient’s perfusion status is not addressed, the rest will not matter.</p><p class="MsoNormal">When students are taking an ECG class, they most often want to know, “what is the name of this rhythm?” and “what are some shortcuts or mnemonics I can use to remember the names of the rhythms?”.<span style="mso-spacerun: yes;">&nbsp; </span>They will be distressed if the instructor says, “This could be second-degree AVB, or we could call it high-grade AVB, or a longer strip might show it to be third-degree AVB.”<span style="mso-spacerun: yes;">&nbsp; </span>The instructor may even feel distressed by not knowing “for sure.”<span style="mso-spacerun: yes;">&nbsp; </span>But (and this is admittedly an editorial on my part), I think we do our students a disservice to lead them to believe that there is a “right” answer to every ECG strip. They need to know that some ECGs cannot and should not be read in a vacuum, but rather in light of the patient’s information. They need to know that comparison with a previous ECG, or adding additional leads, or running a longer strip may illuminate the problem.<span style="mso-spacerun: yes;">&nbsp; </span>But most of all, they should understand what immediate actions can safely be taken until we do “know for sure”.</p><p class="MsoNormal">We welcome your comments on this topic, whether you are a teacher, a student, a provider, or all of these.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/119/feed" method="post" id="fivestar-custom-widget--8" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--16" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give High-grade AV Block With Profound Bradycardia 1/5</option><option value="40">Give High-grade AV Block With Profound Bradycardia 2/5</option><option value="60">Give High-grade AV Block With Profound Bradycardia 3/5</option><option value="80" selected="selected">Give High-grade AV Block With Profound Bradycardia 4/5</option><option value="100">Give High-grade AV Block With Profound Bradycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.5</span></span> <span class="total-votes">(<span >27</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--8" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-r9_8bsLpHfjk-gwrc8mgGkGoDhDIrFzz_qp0m43fYMA" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/high-grade-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">High-grade AV Block</a></div><div class="field-item odd"><a href="/ecg/sinus-bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus bradycardia</a></div><div class="field-item even"><a href="/ecg/second-degree-av-block-type-ii" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Second-degree AV block Type II</a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item even"><a href="/ecg/left-anterior-fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior fascicular block</a></div><div class="field-item odd"><a href="/ecg/left-anterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior hemiblock</a></div><div class="field-item even"><a href="/ecg/bifascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bifascicular block</a></div><div class="field-item odd"><a href="/ecg/first-degree-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">First-degree AV block</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_8"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fhigh-grade-av-block-profound-bradycardia&amp;title=High-grade%20AV%20Block%20With%20Profound%20Bradycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 04 Jun 2020 20:24:18 +0000 Dawn 785 at https://www.ecgguru.com https://www.ecgguru.com/ecg/high-grade-av-block-profound-bradycardia#comments Shark Fin Pattern https://www.ecgguru.com/ecg/shark-fin-pattern <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/shark-fin-pattern"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/1025%20initial%20RS.jpg" width="1000" height="153" alt="" /></a></div><div class="field-item odd"><a href="/ecg/shark-fin-pattern"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20Lead%20jpg.jpg" width="1800" height="596" alt="" /></a></div><div class="field-item even"><a href="/ecg/shark-fin-pattern"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20Lead%20with%20J%20points%20and%20P%20waves%20marked.jpg" width="1800" height="596" alt="" /></a></div><div class="field-item odd"><a href="/ecg/shark-fin-pattern"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/1041%20Rhythm%20Strip%20e.jpg" width="1000" height="255" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong><span style="color: #009999;">The Patient:</span></strong><span style="mso-spacerun: yes;">&nbsp; </span>This ECG is from a 59-year-old woman who was found by the EMS crew to be unresponsive, with agonal respirations at about 6 breaths per minute. Her pulse was thready at the carotid, and absent peripherally. Her skin was pale, cool, and mottled.<span style="mso-spacerun: yes;">&nbsp; </span>Her BP via the monitor is 81/40, peripheral pulses not being palpable.<span style="mso-spacerun: yes;">&nbsp; </span>An <strong>initial rhythm strip</strong> showed sinus rhythm at 75 bpm with right bundle branch block and ST elevation.</p><p class="MsoNormal">The patient’s husband gave a history of “difficulty breathing” since sometime this morning, alcohol dependence, hypertension, tobacco use, and insomnia. He said she had been drinking heavily for several weeks.</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">She was immediately ventilated and intubated, and an intraosseous infusion line established.<span style="mso-spacerun: yes;">&nbsp; </span>A<strong>12-lead ECG</strong> was done, and it showed a dramatic change in the rhythm and ST segments over the initial strip. She was transported to a nearby hospital with CPR support. She <span style="color: #0d0d0d; mso-themecolor: text1; mso-themetint: 242; mso-style-textfill-fill-color: #0D0D0D; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: 'lumm=95000 lumo=5000';">achieved return of spontaneous circulation (ROSC) at the Emergency Department, after having three doses of epinephrine.<span style="mso-spacerun: yes;">&nbsp; </span>Follow up with the ED physician revealed that the patient had suffered a massive gastrointestinal bleed.<span style="mso-spacerun: yes;">&nbsp; </span></span>This patient, due to loss of a critical amount of blood, had low blood pressure and very poor perfusion, which resulted in damage to her heart (and possibly other organs as well). <span style="color: #0d0d0d; mso-themecolor: text1; mso-themetint: 242; mso-style-textfill-fill-color: #0D0D0D; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: 'lumm=95000 lumo=5000';">I do not have further follow up, but will update this if I receive more information.</span>&nbsp;</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><strong><span style="color: #009999;">The ECG:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="color: #0d0d0d; mso-themecolor: text1; mso-themetint: 242; mso-style-textfill-fill-color: #0D0D0D; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: 'lumm=95000 lumo=5000';">The 12-Lead ECG done several minutes into the call is very different from the original rhythm strip.</span> The P waves are slightly irregular, with an average rate of about 47 bpm. (Marked with blue arrows on the labeled ECG).<span style="mso-spacerun: yes;">&nbsp;</span>The QRS complexes are also slightly irregular, but not at all related to the P waves.<span style="mso-spacerun: yes;">&nbsp; </span>It appears to be a right bundle branch block pattern, with a pathological Q wave in V1. Because of the ST changes, it isn’t possible to discern a small S wave in Leads I and V6, as we would normally see in RBBB.<span style="mso-spacerun: yes;">&nbsp; </span>This appears to be a junctional rhythm that averages about 51 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>I would call this a complete heart block, even though complete heart block usually implies that the atrial rate will be faster than the escape rhythm.<span style="mso-spacerun: yes;">&nbsp; </span>In this ECG, I see no signs of the P waves conducting, even when they have ample opportunity – that is, they have not fallen into a refractory period. In fact, a few minutes after the 12-lead ECG was done, there was a period recorded of about four seconds with P waves only.</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">&nbsp;The most notable feature of this ECG is that there is <strong>extreme ST segment elevation</strong> in all leads except aVR and aVL.&nbsp; The J points are so high, it appears that the QRS complexes are extremely wide.&nbsp; A second view of this ECG is provided with the J points marked with red lines to help you see where the QRS ends and the ST segment begins.&nbsp; These types of ST segment elevations are often called <strong>“shark fin”</strong> pattern. Rather than wide QRS, this pattern represents a blending of the QRS and T wave. Shark fin pattern is often seen in “related leads”, leads that are oriented to one coronary artery.&nbsp; In this case, the ST elevations are very widespread.&nbsp; Without knowing this patient’s outcome, I can only make an educated guess, that this is a Type 2 M.I.&nbsp; Type 2 M.I. is defined as an M.I. caused by a mismatch between cardiac supply and demand, rather than by thrombosis.&nbsp; Especially in coronary arteries that are narrowed by disease, a low-perfusion state can cause myocardial damage and elevated troponins.&nbsp;This patient has severe hypovolemia and anemia due to her G.I. bleed.&nbsp; Another possibility is an occlusion from a thrombus in a dominant artery. For example, one of the branches of the left coronary artery could wrap around and perfuse the inferior wall, which is usually the right coronary artery's territory. An occlusion in a markedly dominant artery can cause widespread ST changes.&nbsp; I would be very interested in hearing your thoughts on this.</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">For more information on shark fin pattern, and myocardial infarction in general, we highly recommend Dr. Steven Smith’s excellent blog.&nbsp; Dr. Smith is an authority on M.I. ECG changes, and the shark fin pattern.&nbsp; <a href="http://www.hqmeded-ecg.blogspot.com/">http://www.hqmeded-ecg.blogspot.com</a></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/119/feed" method="post" id="fivestar-custom-widget--9" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--18" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Shark Fin Pattern 1/5</option><option value="40">Give Shark Fin Pattern 2/5</option><option value="60" selected="selected">Give Shark Fin Pattern 3/5</option><option value="80">Give Shark Fin Pattern 4/5</option><option value="100">Give Shark Fin Pattern 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3</span></span> <span class="total-votes">(<span >51</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--9" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-QAM7tJxYqJhf44-0tHf_DjlfZWsI4c8VPCNHPRmDeKQ" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/sharks-fin-pattern" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sharks fin pattern</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/type-2-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Type 2 M.I.</a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item even"><a href="/ecg/third-degree-av-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Third-degree AV block</a></div><div class="field-item odd"><a href="/ecg/complete-heart-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete heart block</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_9"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fshark-fin-pattern&amp;title=Shark%20Fin%20Pattern"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 28 Jan 2020 03:54:43 +0000 Dawn 781 at https://www.ecgguru.com https://www.ecgguru.com/ecg/shark-fin-pattern#comments Tachycardia In An Unresponsive Patient https://www.ecgguru.com/ecg/tachycardia-unresponsive-patient <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/tachycardia-unresponsive-patient"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Tachycardia%20and%20Hyperkalemia.jpg" width="1800" height="713" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;">&nbsp;</strong><strong style="font-size: 13.008px;"><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">The Patient</span></strong><span style="font-size: 10pt; line-height: 107%; color: #00b050;">&nbsp;&nbsp;&nbsp;&nbsp; </span><span style="font-size: 10pt; line-height: 107%;">This ECG was obtained from a 28-year-old woman who was found in her home, unresponsive.&nbsp; She was hypotensive at 99/35.&nbsp; No one was available to provide information about past medical history or the onset of this event.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">Before you read my comments, pause to look at the ECG and see what YOU think.<span style="mso-spacerun: yes;">&nbsp; </span>We would welcome comments below from all our members!</span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">The ECG</span></strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><span style="font-size: 10.0pt; line-height: 107%;">This ECG is quite challenging, as it illustrates the helpfulness of ECG changes in patient diagnosis, and also points out how important clinical correlation is when the ECG suggests multiple different problems. Forgive me in advance, but there is a lot to say about this ECG.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">The <strong style="mso-bidi-font-weight: normal;">heart rate</strong> is 148 bpm, and the <strong style="mso-bidi-font-weight: normal;">rhythm is regular</strong>, although not perfectly. <strong style="mso-bidi-font-weight: normal;">P waves</strong> are not seen, even though the ECG machine gives a P wave axis and PR interval measurement. The rate is fast enough to bury the P waves in the preceding T waves, especially if there is first-degree AV block. <strong style="mso-bidi-font-weight: normal;"><em style="mso-bidi-font-style: normal;"><span style="color: #7030a0;">Differential dx</span></em></strong><em style="mso-bidi-font-style: normal;"><span style="color: #7030a0;">:</span></em><span style="color: #7030a0;"> sinus tachycardia, PSVT, atrial flutter. </span>The very slight irregularity points more towards sinus tachycardia.<span style="mso-spacerun: yes;">&nbsp; </span>The rate of nearly 150 suggests atrial flutter with 2:1 conduction, but the only lead that looks remotely like it has flutter waves is V2. The lack of an onset or offset of the rhythm makes it difficult to diagnose PSVT with any certainty. </span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">The ECG machine measures the QRS complex at .102 seconds (102 ms). I don’t believe this is correct, as the QRS has an additional wave due to <strong style="mso-bidi-font-weight: normal;"><a href="https://www.ecgguru.com/ecg/instructors-collection-ecg-week-september-23-2015-right-bundle-branch-block-0">right bundle branch block pattern</a></strong>, and the machine did not count this terminal wave.<span style="mso-spacerun: yes;">&nbsp; </span>I measure the actual <strong style="mso-bidi-font-weight: normal;">QRS duration</strong> at closer to .12 seconds (120 ms).<span style="mso-spacerun: yes;">&nbsp; </span>The J point, or end point of the QRS complex, is difficult to see in most of the leads because of slurring from the QRS to the ST segment.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><em style="mso-bidi-font-style: normal;"><span style="font-size: 10.0pt; line-height: 107%; color: #7030a0;">Differential dx:</span></em></strong><span style="font-size: 10.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>There are some signs of <strong style="mso-bidi-font-weight: normal;"><a href="https://litfl.com/ecg-changes-in-pulmonary-embolism/">right ventricular failure</a></strong> on this ECG, but ECG is not 100% accurate for determining right heart strain. The ECG evidence must be confirmed by clinical correlation. <span style="mso-spacerun: yes;">&nbsp;</span>In a young person with sudden onset of right heart failure signs, one must consider <strong style="mso-bidi-font-weight: normal;">pulmonary embolus</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>Some, but not all, of the ECG signs that can be associated with pulmonary embolism are:</span></p><p class="MsoListParagraphCxSpFirst" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Sinus tachycardia (44%)</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right bundle branch block or incomplete RBBB (18%)</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right ventricular strain: T wave inversion in right precordial leads and inferior leads (only present here in V1 and Lead III, which is often normal).</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right axis deviation (16%).<span style="mso-spacerun: yes;">&nbsp; </span>Present here, but not severe at around 100 degrees.</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">S1 – Q3 – T3 the “classic” but not often present, sign of pulmonary embolism.<span style="mso-spacerun: yes;">&nbsp; </span>The<span style="mso-spacerun: yes;">&nbsp; </span>S wave in I may simply be the RBBB and the Q wave with T wave inversion may be a normal variant.</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Non-specific ST segment and T wave changes (50%)</span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">P pulmonale (we cannot see P waves)</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">There are also ST and T wave changes that resemble <strong style="mso-bidi-font-weight: normal;"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6282764/">Brugada Syndrome</a>, </strong>a genetic disorder of the sodium channel that can cause sudden death.<span style="mso-spacerun: yes;">&nbsp; </span>Illness can unmask the ECG changes that point to Brugada syndrome, but also there are conditions that cause similar ECG changes without the patient actually having a channelopathy. The shape of the ST and inverted T wave in V1 here are “Brugada like”. In Brugada Syndrome, those changes are usually seen in V1 and V2.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">The loss of P waves and the tall, peaked T waves with narrow bases are indicative of <strong style="mso-bidi-font-weight: normal;"><a href="https://rebelem.com/ecg-changes-hyperkalemia/">hyperkalemia</a></strong>. It is difficult to determine just from the ECG how far along the patient is in serum potassium levels, but widening of the QRS with loss of voltage is a dire sign.<span style="mso-spacerun: yes;">&nbsp; </span>Because hyperkalemia can progress swiftly to a “sine wave” pattern, it is crucial to make the diagnosis and begin treatment as soon as possible.<span style="mso-spacerun: yes;">&nbsp; </span>Usually, the serum K is high because the K has moved out of the intracellular space and entered the serum. Rather than remove K from the body, it is necessary to “push” it back into the cells, where it rightly belongs.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal" style="margin-bottom: .0001pt;"><span style="font-size: 10.0pt; line-height: 107%;">And, to make matters even more confusing, this ECG show signs of drug toxicity, specifically <strong style="mso-bidi-font-weight: normal;"><a href="https://litfl.com/tricyclic-overdose-sodium-channel-blocker-toxicity/">sodium channel blocker overdose</a>.<span style="mso-spacerun: yes;">&nbsp; </span></strong>Tricyclic antidepressants and some antiarrhythmics fall into this broad category. <span style="mso-spacerun: yes;">&nbsp;</span>Remember, this patient was found unresponsive, and we have no remote OR recent medical history.<span style="mso-spacerun: yes;">&nbsp; </span>Everything is on the table.<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span><span style="mso-spacerun: yes;">&nbsp;</span>ECG signs of sodium channel blocker OD include:</span></p><p class="MsoListParagraphCxSpFirst" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Sinus tachycardia</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Wide QRS complex</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Prolongation of the PR interval or QT interval</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right bundle branch block</span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Brugada pattern</span></p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 10.0pt; color: #00b050;">Hospital Follow Up<span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span></strong><span style="font-size: 10.0pt;">At this time, we have only a preliminary follow up report.<span style="mso-spacerun: yes;">&nbsp; </span>Notably, this young woman was found to be in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298445/">diabetic ketoacidosis</a>, with a blood glucose level of 1,332 mg/dL! As a result, she was also hyperkalemic, with a serum potassium of 8.2.<span style="mso-spacerun: yes;">&nbsp; </span>The severe dehydration and acidosis of DKA cause sinus tachycardia.</span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><em style="mso-bidi-font-style: normal;"><span style="font-size: 10.0pt; line-height: 107%; color: #595959; mso-themecolor: text1; mso-themetint: 166; mso-style-textfill-fill-color: #595959; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: 'lumm=65000 lumo=35000';">Thanks to Sebastian Garay for donating this interesting ECG.</span></em></strong></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/119/feed" method="post" 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class="field-item odd"><a href="/ecg/bifascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bifascicular block</a></div><div class="field-item even"><a href="/ecg/left-posterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior hemiblock</a></div><div class="field-item odd"><a href="/ecg/right-axis-deviation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right axis deviation</a></div><div class="field-item even"><a href="/ecg/sa-exit-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">SA exit block</a></div><div class="field-item odd"><a href="/ecg/wide-qrs-complex" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide QRS complex</a></div><div class="field-item even"><a href="/ecg/diabetic-ketoacidosis" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Diabetic ketoacidosis</a></div><div class="field-item odd"><a href="/ecg/hyperkalemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperkalemia</a></div><div class="field-item even"><a href="/ecg/brugada-sign" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Brugada sign</a></div><div class="field-item odd"><a href="/ecg/tricyclic-antidepressant-overdose" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Tricyclic antidepressant overdose</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_10"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Ftachycardia-unresponsive-patient&amp;title=Tachycardia%20In%20An%20Unresponsive%20Patient"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 21 Aug 2019 02:48:51 +0000 Dawn 775 at 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