ECG Guru - Instructor Resources - Complete heart block https://www.ecgguru.com/ecg/complete-heart-block-1 en Complete Heart Block or High Grade AVB? https://www.ecgguru.com/ecg/complete-heart-block-or-high-grade-avb <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/complete-heart-block-or-high-grade-avb"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/032007%20Complete%20AVB%20w%20Junctional%20escape%20edit.jpg" width="1800" height="1471" 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"><strong><span style="color: #00b050;">The patient:</span></strong><span style="mso-spacerun: yes;">&nbsp; </span>This ECG was obtained from a 91-year-old woman who was complaining of weakness.<span style="mso-spacerun: yes;">&nbsp; </span>Unfortunately, we have no other information.<span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The ECG:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong>This ECG has something for your basic students, and even more for the more advanced learners.<span style="mso-spacerun: yes;">&nbsp; </span>The first thing&nbsp; that anyone should notice is the slow rate.<span style="mso-spacerun: yes;">&nbsp; </span>The ventricular rate is around 35 bpm, and regular.<span style="mso-spacerun: yes;">&nbsp; </span>If the patient is showing signs of poor perfusion, we would stop here and prepare to increase the rate with a temporary pacemaker (transvenous or transcutaneous). Why is the rate so slow?&nbsp; There is no P wave in front of each QRS, so this is not sinus bradycardia.&nbsp; Rather, we see P waves at a rate of approximately 100 bpm, wit a very regular rhythm.&nbsp; Beginners should “march out” the P waves with calipers or by marking a straight edge piece of paper.&nbsp; There are 15 P waves on this ECG – some are buried within QRS complexes (QRS #3) or T waves (QRS #4).</p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;Because there are two distinct, regular rhythms, but they do not track with one another, we know this is possibly&nbsp;<strong>third-degree AV block</strong> (complete heart block).&nbsp; Another clue is that there are no steady, repetitive PR intervals, which means there is no relationship between the atrial rhythm and the ventricular rhythm.</p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;For more advanced learners, it is helpful to try to identify the origin of the escape rhythm.&nbsp; If it is junctional, the AV block is above the junction.&nbsp; If the escape is ventricular, the AV block is below the junction.&nbsp; A junctional rhythm is usually between 40 – 60 bpm, with a narrow QRS.&nbsp; Ventricular escape rhythms are usually less than 40 bpm and with wide QRS complexes.&nbsp;&nbsp;<span style="font-size: 8pt; line-height: 107%;">&nbsp;T</span>his ECG will be a little challenging on this front, because the rhythm has some characteristics of junctional rhythm and of ventricular rhythm.</p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;<span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span>·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><strong style="text-indent: -0.25in;">The QRS is wide</strong><span style="text-indent: -0.25in;">.</span><span style="mso-spacerun: yes;">&nbsp; </span><span style="text-indent: -0.25in;">Normally, that finding favors the diagnosis of ventricular rhythm, but interventricular conduction delays like bundle branch block can widen a junctional QRS. There is a small R’ in V1 and a wide little S wave in I and V6, favoring the diagnosis of right bundle branch block.</span><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><strong style="text-indent: -0.25in;">The frontal plane axis is abnormal</strong><span style="text-indent: -0.25in;">.</span><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span><span style="text-indent: -0.25in;">This can be a sign of a ventricular rhythm, because the axis reflects the direction of the electrical flow in the ventricles.</span><span style="mso-spacerun: yes;">&nbsp; </span><span style="text-indent: -0.25in;">But, this left axis deviation is also seen in left anterior fascicular block, which is frequently paired with RBBB.</span><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><strong style="text-indent: -0.25in;">The slow rate</strong><span style="text-indent: -0.25in;"> is just about on the border between the intrinsic rates of the junctional and ventricular pacemakers.&nbsp;</span><span style="text-indent: -0.25in;">&nbsp;For those who care for patients in an emergency or primary care setting, it is important to emphasize that the origin of the block is not as important as supporting the patient’s need for rate as part of the important cardiac output equation.&nbsp;&nbsp;</span><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span><span style="text-indent: -0.25in;">Another consideration for this patient is “what caused the AV block”?&nbsp; She is very old, and that certainly is a factor.&nbsp; But, on close inspection, we see ST changes.&nbsp; Specifically, there are flattened, slightly depressed ST segments in II, III, and aVF.&nbsp; AVR has the same flat shape, with some elevation. V1 has a very subtle ST changes, as well.&nbsp; This is a sign of diffuse ischemia (chronic or acute).&nbsp; The machine read the QTc as prolonged, but I measured using an online measuring tool, and got 464.8 with the Bazett equation.&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left">&nbsp;ECGs should always be approached in a systematic manner.&nbsp; When possible, patient presentation and symptoms should inform one’s decisions.</p><p class="MsoNormal" style="text-align: left;" align="left">EDIT:&nbsp; Please read the comment below from David Richley and Ken Grauer.&nbsp; They bring up a very good argument for "high-grade" AVB, which is a good conversation to have with more advanced students.&nbsp;&nbsp;</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/191/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 Complete Heart Block or High Grade AVB? 1/5</option><option value="40">Give Complete Heart Block or High Grade AVB? 2/5</option><option value="60">Give Complete Heart Block or High Grade AVB? 3/5</option><option value="80" selected="selected">Give Complete Heart Block or High Grade AVB? 4/5</option><option value="100">Give Complete Heart Block or High Grade AVB? 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.6</span></span> <span class="total-votes">(<span >5</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-NPM24LoVosZNnvpSlPHfvs-6Jui-Nou9P8fG-EKPrcE" /> <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/subtle-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Subtle ST changes</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/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/junctional-escape-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional escape rhythm</a></div><div class="field-item even"><a href="/ecg/idioventricular-escape-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Idioventricular escape rhythm</a></div><div class="field-item odd"><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 even"><a href="/ecg/diffuse-ischemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Diffuse ischemia</a></div><div class="field-item odd"><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_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fcomplete-heart-block-or-high-grade-avb&amp;title=Complete%20Heart%20Block%20or%20High%20Grade%20AVB%3F"><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> Wed, 11 Oct 2023 21:22:59 +0000 Dawn 873 at https://www.ecgguru.com https://www.ecgguru.com/ecg/complete-heart-block-or-high-grade-avb#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/191/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 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--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-EvHYGRH-ugACLGJVciocISDvoPzTXTbNlmvh5JCtTpo" /> <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_2"> <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 Inferior Wall M.I. With Wide QRS and Complete AV Block https://www.ecgguru.com/ecg/inferior-wall-mi-wide-qrs-and-complete-av-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/inferior-wall-mi-wide-qrs-and-complete-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWMI%20LBBB%20101_0.jpg" width="1800" height="802" alt="" /></a></div><div class="field-item odd"><a href="/ecg/inferior-wall-mi-wide-qrs-and-complete-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWMI%20WC%20101%20Follow%20up%20post%20cath.jpg" width="453" height="132" 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><span style="font-size: 13.008px;">This ECG is from a 66-year-old woman who called 911 for a complaint of chest pain for the past four hours. She also complained of nausea, vomiting, and diarrhea for that time.</span><span style="font-size: 13.008px;">&nbsp;She was pale and diaphoretic, and her BP was 77/43 sitting up, improving to 90/54 reclining.&nbsp;</span><span style="font-size: 13.008px;">She denied “cardiac” history.</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">Her medications included:</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">aspirin, an SSRI, cilostazol, amlodipine, umeclidinium and vilanterol inhaler, atorvastatin, levothyroid, and metoprolol. We don’t have a previous ECG.</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">The EMS crew followed their chest pain protocol and delivered the patient to a facility with an interventional cath lab, but they did not designate a “STEMI Alert” because of the wide QRS.</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">It is their protocol to use the term “STEMI Alert” only when no M.I. mimics, such as left bundle branch block, are present.</span><span style="font-size: 13.008px;">&nbsp;</span></p><p class="MsoNormal"><strong>What does this ECG show? &nbsp;&nbsp;&nbsp;&nbsp;</strong>There is an underlying sinus rhythm at 75 bpm.&nbsp; There is AV dissociation, with regular, wide QRS complexes at a rate of 44 bpm.&nbsp; &nbsp;This meets the criteria for complete heart block (third-degree AV block).&nbsp; The morphology of the QRS complexes meets the criteria for left bundle branch block (wide, upright in Leads I and V6, negative in V1).&nbsp; At a rate of 44 bpm, several options for this escape rhythm are possible:&nbsp; 1)&nbsp; junctional escape with LBBB, 2) junctional escape with intraventricular conduction delay due to AMI,&nbsp; and 3) idioventricular escape rhythm.&nbsp; &nbsp;Also, in the presence of IWMI, AV node ischemia is very likely, resulting in AV blocks at the level of the AV node. &nbsp;CHB at the AV node would result in junctional escape rhythm, and CHB below that, in the fascicles of the bundle branches, would result in idioventricular escape. The issue for this patient, and ANY patient, is cardiac output, and we see several reasons for cardiac output to be lower:</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="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><strong>Wide QRS</strong></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="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><strong>Slow rate</strong></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="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><strong>Lack of P waves preceding every QRS (loss of atrial kick).</strong></p><p class="MsoNormal">In the EMS setting, it really doesn’t matter if the escape rhythm is junctional with wide QRS or ventricular. &nbsp;The patient's hemodynamic status is the important consideration.</p><p class="MsoNormal"><strong>Even more alarming, </strong>this ECG shows signs of acute inferior wall M.I.&nbsp; It can be difficult to ascertain when STEMI is present in the presence of wide-complex rhythms.&nbsp; That is because most wide-complex rhythms have <em>discordant ST and T wave changes.</em>&nbsp; That is, whenever the wide QRS is positive, there is ST depression and T wave inversion, and whenever the wide QRS is negative, there is ST elevation and upright T waves.</p><p class="MsoNormal">This ECG shows excessively elevated discordant ST segments in the inferior leads (II, III, and aVF.)&nbsp; We also see <em>excessively discordant&nbsp;</em>ST elevation in V3, and V4. The change from ST depression to ST elevation between V2 and V3 is very abrupt, with the obvious ST depression in V1 and V2 indicating reciprocal views of ST elevation on the posterior wall. &nbsp;In LBBB without STEMI, there is normally ST elevation in V1 a V3.</p><p class="MsoNormal"><strong>Sgarbossa and Smith</strong>&nbsp;&nbsp;&nbsp; In 1996, Sgarbossa, et al proposed a univariate scoring system for determining acute M.I. in the presence of LBBB.&nbsp; <a href="https://lifeinthefastlane.com/ecg-library/basics/sgarbossa/">Sgarbossa’s Criteria</a> has been used for with some success both in the presence of LBBB and ventricular paced rhythms.&nbsp; These criteria were formulated before results could be confirmed with cath lab results.&nbsp; In this decade, Dr. Steven Smith and his colleagues have proposed some <a href="https://vimeo.com/34634434">modifications to Sgarbossa’s Criteria</a> which take into account the ratio of ST alteration to R wave. In Smith’s Modification, excessive discordance is measured as discordant ST elevation when the j point is &gt; 0.25, or 25% the depth of the S wave. &nbsp;His results have been, and continue to be, measured against cath lab findings, and are more accurate than the original criteria. &nbsp;For an excellent discussion of LBBB, Sgarbossa’s Criteria, and Smith’s modified Sgarbossa criteria, we recommend Tom’s Bouthillet’s excellent <a href="https://www.ecgmedicaltraining.com/making-sense-of-sgarbossas-criteria-chest-pain-and-left-bundle-branch-block-part-1/">three-part series</a> on the topic.</p><p class="MsoNormal">With the exception of right bundle branch block, most wide-QRS conditions are considered “mimics” of acute M.I., and can both disguise the presence of an M.I. and masquerade as M.I.&nbsp; Unfortunately, the mimics do not <em>prevent</em> the patient from having an M.I.</p><p class="MsoNormal"><strong>How did this patient do?&nbsp;&nbsp; </strong>The infero-lateral M.I. was recognized in the emergency department, and the patient’s hypotension was treated with pacing and fluids. She was sent immediately to the cath lab, where it was found that she had a single-vessel lesion in the proximal to mid right coronary artery. There was 100% occlusion with TIMI-0 flow. She underwent angioplasty and stent placement, with excellent TIMI-III results.&nbsp;<span style="font-size: 13.008px;">&nbsp;The RCA was dominant, and much larger than the LCA. The second ECG shows the excellent results of the angioplasty - QRS is narrow, the rhythm is sinus, and ST segments returning to normal. The tiny Q wave in Lead III eventually disappeared, probably because it was due to right ventricular M.I.</span></p><p class="MsoNormal">This crew felt they were following their protocol in not calling this a “STEMI Alert”, but fortunately they were able to transport the patient to a full-service cardiac hospital, where she received angioplasty very quickly.&nbsp;<strong></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/191/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 Inferior Wall M.I. With Wide QRS and Complete AV Block 1/5</option><option value="40">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 2/5</option><option value="60">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 3/5</option><option value="80">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 4/5</option><option value="100" selected="selected">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.2</span></span> <span class="total-votes">(<span >5</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-plnfslKuVXyVxi4X7q5h7_R-5a8H70Xz-ud01XgViFU" /> <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/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item odd"><a href="/ecg/intraventricular-conduction-delay" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Intraventricular conduction delay</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/complete-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete AV block</a></div><div class="field-item odd"><a href="/ecg/inferior-lateral-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-lateral 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 class="field-item even"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</a></div><div class="field-item odd"><a href="/ecg/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</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%2Finferior-wall-mi-wide-qrs-and-complete-av-block&amp;title=Inferior%20Wall%20M.I.%20With%20Wide%20QRS%20and%20Complete%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> Wed, 28 Jun 2017 20:13:14 +0000 Dawn 733 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-wall-mi-wide-qrs-and-complete-av-block#comments Paced Rhythm Following AV Node Ablation https://www.ecgguru.com/ecg/paced-rhythm-following-av-node-ablation <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/paced-rhythm-following-av-node-ablation"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/PM%20110%20AV%20Pacing%20post%20AVN%20ablation.jpg" width="1800" height="912" 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">This ECG is taken from a woman who had suffered for several years with intractable intermittent atrial fibrillation. She had tolerated medications poorly, and several attempts at electric cardioversion had resulted in only temporary relief. Ultimately, she chose to undergo AV node ablation.&nbsp; In the electrophysiology lab, her AV node was destroyed, preventing the atrial fib impulses from penetrating into the ventricles.&nbsp; This resulted in a “man-made” complete AV block.&nbsp; A pacemaker was implanted in the EP lab.&nbsp; When she is in atrial fibrillation, the fibrillatory waves of the atria INHIBIT the atrial pacing electrode from firing, so she has no paced P waves at that time.&nbsp; The right ventricular pacing electrode functions without inhibition, and makes a wide QRS complex with a leftward axis deviation (normal for RV pacing).<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal">In this ECG, we see the patient WITHOUT atrial fib, and the pacemaker is pacing the atria AND the ventricles, in a sequential fashion.&nbsp; The spikes are very hard to see, as this is a “bipolar” pacemaker, which makes much smaller spikes than a “unipolar” pacemaker.&nbsp; Some ECG machines will automatically enhance the spikes, but this one did not.&nbsp; We have marked a “sample” atrial spike in blue for you and one of the ventricular spikes in red.&nbsp; Each beat on this ECG actually has appropriately-timed atrial and ventricular stimuli (spikes), and the patient has optimized cardiac output provided by the “atrial kick”. A P wave occurring just before a QRS indicates that the ventricles are filling from the forceful contraction of the atria.&nbsp; This provides much better filling than when the atria are not beating or are fibrillating.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal">This is a good ECG to use to show your students how we can recognize a paced rhythm without being sure of the spikes.&nbsp; Of course, without other evidence (patient history and exam), we can’t know for sure that this is a paced rhythm, but the steady, normal rate, wide complexes, and left axis deviation are signs of RV pacing.&nbsp; Look for negatively-deflected QRS complexes in II, III, and aVF and positive QRSs in aVL and aVR.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal">When pacing only one ventricle, the impulse travels relatively slowly through the other ventricle, resulting in wide QRS complexes.&nbsp; This then results in SECONDARY ST-T WAVE CHANGES.&nbsp; Wherever the QRS is positive, you will normally see some ST depression and T wave inversion.&nbsp; In leads with negative QRS complexes, the opposite is true, and you will see ST elevation and upright T waves.&nbsp; This can make evaluation of ST segments for acute M.I. difficult.</p><p>&nbsp;</p><p class="MsoNormal">&nbsp;&nbsp;&nbsp;&nbsp;</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/191/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 Paced Rhythm Following AV Node Ablation 1/5</option><option value="40">Give Paced Rhythm Following AV Node Ablation 2/5</option><option value="60">Give Paced Rhythm Following AV Node Ablation 3/5</option><option value="80">Give Paced Rhythm Following AV Node Ablation 4/5</option><option value="100" selected="selected">Give Paced Rhythm Following AV Node Ablation 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.7</span></span> <span class="total-votes">(<span >6</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-0NaLAoX-9OBUa_pKSC4UPeHExVZDYcr4wFYTrFdnj1Y" /> <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/pacemaker" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pacemaker</a></div><div class="field-item odd"><a href="/ecg/paced-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Paced rhythm</a></div><div class="field-item even"><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 odd"><a href="/ecg/complete-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete 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_4"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fpaced-rhythm-following-av-node-ablation&amp;title=Paced%20Rhythm%20Following%20AV%20Node%20Ablation"><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 Dec 2015 02:38:52 +0000 Dawn 682 at https://www.ecgguru.com https://www.ecgguru.com/ecg/paced-rhythm-following-av-node-ablation#comments ECG Basics: Third-degree AV Block, Complete Heart Block https://www.ecgguru.com/ecg/ecg-basics-third-degree-av-block-complete-heart-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/ecg-basics-third-degree-av-block-complete-heart-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/156%20CHB.jpg" width="1952" height="354" 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>This rhythm strip shows third-degree AV block, also called complete heart block or complete AV block. &nbsp;The P waves are from the sinus node, and are regular at a rate of about 120/min. (Sinus tachycardia). This is a good strip for showing your students how to "march out" the P waves to find the ones that are hidden behind QRS complexes or T waves. Knowing that the P waves are regular, it is easy to find the hidden ones.</p><p>The QRS complexes are wide at 0.14 seconds, and regular, with a rate of about 28/min. &nbsp;On first glance, it APPEARS that there are PR intervals. &nbsp;That is, it appears that some of the P waves are conducting. If you measure the PR intervals carefully, you will note that they are NOT equal. &nbsp;There is no connection between the P waves and the QRS complexes - this strip has just caught them near each other. &nbsp;If we ran the strip longer, we would see the PR intervals "come apart", proving they are not real. &nbsp;The QRS complexes are coming from an IDIOVENTRICULAR ESCAPE RHYTHM. &nbsp;They are regular, wide, have no P waves associated with them, and the rate is below 40 bpm.</p><p>Patients with CHB that results in a very slow heart rate sometimes need emergency treatment aimed at increasing the rate. &nbsp;When the escape rhythm is idioventricular, it is assumed that the AV block is located below the AV node, and emergency temporary pacing is often the method of choice. &nbsp;In fact, a permanent implanted pacemaker is almost always needed. &nbsp;When the AV block is located in the AV node, the escape rhythm will be junctional (narrow QRS complexes, rate about 40-60 bpm). &nbsp; &nbsp;&nbsp;</p><p>&nbsp;</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/191/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 ECG Basics: Third-degree AV Block, Complete Heart Block 1/5</option><option value="40">Give ECG Basics: Third-degree AV Block, Complete Heart Block 2/5</option><option value="60">Give ECG Basics: Third-degree AV Block, Complete Heart Block 3/5</option><option value="80" selected="selected">Give ECG Basics: Third-degree AV Block, Complete Heart Block 4/5</option><option value="100">Give ECG Basics: Third-degree AV Block, Complete Heart Block 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 >4</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-DCUWY1BCipE7qkTad1CZN4TWihSYWT55fyoLrM83pLU" /> <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/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item odd"><a href="/ecg/basic-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Basic ECG</a></div><div class="field-item even"><a href="/ecg/complete-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete AV block</a></div><div class="field-item odd"><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 even"><a href="/ecg/idioventricular-escape-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Idioventricular escape rhythm</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/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</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%2Fecg-basics-third-degree-av-block-complete-heart-block&amp;title=ECG%20Basics%3A%20%20Third-degree%20AV%20Block%2C%20Complete%20Heart%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 18 Nov 2015 18:31:58 +0000 Dawn 678 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-third-degree-av-block-complete-heart-block#comments ECG Basics: Idioventricular Escape Rhythm https://www.ecgguru.com/ecg/ecg-basics-idioventricular-escape-rhythm-0 <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/ecg-basics-idioventricular-escape-rhythm-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/121%20Idioventricular%20escape%20rhythm.jpg" width="1844" height="397" 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>This six-second monitor strip was from a patient who was designated "Do Not Resuscitate", and whose heart rhythm was slowing dramatically. &nbsp;It shows an idioventricular escape rhythm, with very wide QRS complexes and only two complexes in six seconds. (The top arrows mark three-second segments.) &nbsp;If you look closely at the points marked by the lower arrows, you will see small, uniform, regular P waves. &nbsp;The mechanism leading to this agonal rhythm was complete heart block. &nbsp;A longer strip would show the P waves as all alike, and fairly regular, but slowing. &nbsp;</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/191/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 ECG Basics: Idioventricular Escape Rhythm 1/5</option><option value="40">Give ECG Basics: Idioventricular Escape Rhythm 2/5</option><option value="60">Give ECG Basics: Idioventricular Escape Rhythm 3/5</option><option value="80" selected="selected">Give ECG Basics: Idioventricular Escape Rhythm 4/5</option><option value="100">Give ECG Basics: Idioventricular Escape Rhythm 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--6" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-dksMqRyEu_c2RiDw2A-rLu1_0khGG0p19sMnGG0Qt_I" /> <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/av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AV Block</a></div><div class="field-item odd"><a href="/ecg/agonal-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Agonal rhythm</a></div><div class="field-item even"><a href="/ecg/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item odd"><a href="/ecg/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</a></div><div class="field-item even"><a href="/ecg/basic-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Basic ECG</a></div><div class="field-item odd"><a href="/ecg/idioventricular-escape-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Idioventricular escape rhythm</a></div><div class="field-item even"><a href="/ecg/complete-heart-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete heart 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%2Fecg-basics-idioventricular-escape-rhythm-0&amp;title=ECG%20Basics%3A%20%20Idioventricular%20Escape%20Rhythm"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 12 Nov 2013 20:38:44 +0000 Dawn 515 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-idioventricular-escape-rhythm-0#comments High-grade AV Block vs. Complete Heart Block https://www.ecgguru.com/ecg/complete-heart-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/complete-heart-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB110%20B.jpg" width="1800" height="644" alt="" /></a></div><div class="field-item odd"><a href="/ecg/complete-heart-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB110%20C_0.jpg" width="1800" height="656" 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>This week's ECG of the WEEK was donated to us by Sebastian Garay. These two ECGs were obtained less than 30 seconds apart from an 84 year-old man who called fire-rescue because he felt dizzy and fell. &nbsp;He was not injured in the fall, and his vital signs remained stable, with an adequate BP. &nbsp;These two ECGs were obtained prior to arrival in the Emergency Dept.</p><p>The first one shows a sinus rhythm at about 110/min. &nbsp;There is a complete heart block (third-degree AV block), and the escape rhythm is a wide-complex rhythm at a rate of about 54/min and slowing severely toward the end. &nbsp;The second ECG was taken less than 30 seconds after the first, and shows a significantly slower escape rhythm rate at 27/min., while the sinus rate increases to 120/min. &nbsp;The change is sinus rate is likely an attempt by the nervous system to compensate for the lower cardiac output as the ventricular rate slows. The escape rhythm is not only slower, but there are some changes in the QRS morphology from the first ECG.</p><p>For your <strong>basic students</strong>, this ECG serves to demonstrate the AV dissociation seen in complete heart block. &nbsp;It is easy to "march out" the P waves, and see that some of them are "hiding" in the QRS comlexes. &nbsp;It also shows how quickly a rhythm can change rates.</p><p>For your more <strong>advanced students</strong>, you will want to have a discussion about escape rhythms. &nbsp;This one initially has a fairly fast rate, suggesting junctional origin. The QRS morphology is of the right bundle branch type, with left anterior fascicular block. &nbsp;However, ventricular rhythms originating from the posterior fascicle region can have the "RBBB / LAFB" morphology. &nbsp;If this escape rhythm is fascicular (ventricular) in origin, it is an accelerated idioventricular rhythm. &nbsp;The second escape rhythm appears very similar to the first, with the very noticeable exceptions of QRS morphology, especially in V1 and V2, and the rate.</p><p>This patient was given Atropine in the ED, with no change to the rhythm. &nbsp;We do not know what transpired after that, but suspect a pacemaker was in his future.&nbsp;</p><p><strong>We look forward to comments from our members about these two very interesting ECGs.</strong></p><p><strong>&nbsp;</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/191/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 High-grade AV Block vs. Complete Heart Block 1/5</option><option value="40">Give High-grade AV Block vs. Complete Heart Block 2/5</option><option value="60">Give High-grade AV Block vs. Complete Heart Block 3/5</option><option value="80">Give High-grade AV Block vs. Complete Heart Block 4/5</option><option value="100" selected="selected">Give High-grade AV Block vs. Complete Heart Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >5</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--7" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-IaL_WkN8gh8FGyIF2fnqulaF8EG7MtwnuJwgd7pWqhc" /> <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/complete-heart-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete heart block</a></div><div class="field-item odd"><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 even"><a href="/ecg/high-grade-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">High-grade 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_7"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fcomplete-heart-block&amp;title=High-grade%20AV%20Block%20vs.%20Complete%20Heart%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, 28 Apr 2013 03:38:35 +0000 Dawn 437 at https://www.ecgguru.com https://www.ecgguru.com/ecg/complete-heart-block#comments Third-degree AV Block (Complete Heart Block) https://www.ecgguru.com/ecg/third-degree-av-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/third-degree-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB110%20C_1.jpg" width="1800" height="656" 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>This 84-year-old man called 911 because he felt dizzy and fell.&nbsp; He was not injured in the fall, but the paramedics noted a slow pulse. He denied significant medical history. The initial ECG showed sinus rhythm at about 80&nbsp;bpm&nbsp;and&nbsp;AV dissociation with an apparent acellerated idioventricular rhythm at about 40 bpm.&nbsp; Less than one minute later, he has developed a complete heart block with an idioventricular escape rhythm less than 30 bpm.&nbsp; The escape rhythm speeds slightly toward the end of the strip.&nbsp; He retained stable vital signs and adequate perfusion&nbsp;during transport.&nbsp; It is presumed that he was scheduled for an implanted pacemaker.&nbsp; It is interesting to note the machine's interpretation, and it reminds us to always interpret the ECG ourselves.&nbsp; &nbsp;Thanks to ECG Guru member, Sebmedic, for his contribution of this ECG.&nbsp;</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/191/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 Third-degree AV Block (Complete Heart Block) 1/5</option><option value="40">Give Third-degree AV Block (Complete Heart Block) 2/5</option><option value="60">Give Third-degree AV Block (Complete Heart Block) 3/5</option><option value="80">Give Third-degree AV Block (Complete Heart Block) 4/5</option><option value="100" selected="selected">Give Third-degree AV Block (Complete Heart Block) 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >5</span></span> <span class="total-votes">(<span >1</span> vote)</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-wMRjh02veCJQYLwuek_FbJU9ntfXrzYPQQu1RVBSW1c" /> <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/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/ventricular-escape-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular escape rhythm</a></div><div class="field-item even"><a href="/ecg/av-dissociation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AV dissociation</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/complete-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete 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%2Fthird-degree-av-block&amp;title=Third-degree%20AV%20Block%20%28Complete%20Heart%20Block%29"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 22 Aug 2012 22:37:35 +0000 Dawn 318 at https://www.ecgguru.com https://www.ecgguru.com/ecg/third-degree-av-block#comments