ECG Guru - Instructor Resources - Complete AV block https://www.ecgguru.com/ecg/complete-av-block en Inferior-posterior Wall M.I. and AV Dissociation https://www.ecgguru.com/ecg/inferior-posterior-wall-mi-and-av-dissociation <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-posterior-wall-mi-and-av-dissociation"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWMI%200019.jpg" width="1800" height="1104" alt="" /></a></div><div class="field-item odd"><a href="/ecg/inferior-posterior-wall-mi-and-av-dissociation"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWMI%200019%20for%20Guru%20RS.jpg" width="1800" height="191" 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">At the ECG Guru website, our main goal is to provide quality teaching materials to those who teach ECG interpretation and other cardiac topics.<span style="mso-spacerun: yes;">&nbsp; </span>This ECG offers teaching opportunities for those who teach any level of student.</p><p class="MsoNormal"><strong><span style="color: #00b050;">The patient:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span>This ECG was obtained in the Emergency Department from a 54-year-old man who was complaining of severe chest pain and nausea.<span style="mso-spacerun: yes;">&nbsp; </span>His BP was 130/68.</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 rhythm is interesting and not uncommon in the setting of inferior wall M.I.<span style="mso-spacerun: yes;">&nbsp; </span>The atrial rate is about 158 bpm and the P waves are regular. (Marked in red on accompanying rhythm strip).&nbsp; &nbsp;Some P waves are hidden in T waves or ST segments, but we can see fragments of them. The QRS complexes are narrow and mostly regular at a rate of about 56 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>The second QRS on the strip is early, but from the third QRS on, they are regular. The PR intervals are not consistent.<span style="mso-spacerun: yes;">&nbsp; </span>Careful measurements will show that they get shorter and shorter as the recording progresses.<span style="mso-spacerun: yes;">&nbsp; </span>There are more P waves than QRS complexes and there is NO association between the P waves and the QRS complexes, so there is <strong>AV DISSOCIATION</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>One might argue that the first two QRS complexes are conducted from the P waves, with a shorter PR interval with beat #1 and a longer one with beat #2. This would be a short episode of Wenckebach conduction if that is what is happening.<span style="mso-spacerun: yes;">&nbsp; </span>Since we don’t have a strip preceding this one, we can’t be sure.<span style="mso-spacerun: yes;">&nbsp; </span>Clinically, it is smart to address where the patient is now, and that is <strong>SINUS TACHYCARDIA WITH AV DISSOCIATION AND A JUNCTIONAL</strong> <strong>RHYTHM.</strong> Or, it would be fine, after the first two beats, to say the patient is now in COMPLETE AV BLOCK WITH JUNCTIONAL ESCAPE or THIRD-DEGREE AV BLOCK WITH JUNCTIONAL ESCAPE.<span style="mso-spacerun: yes;">&nbsp; </span>We know that this conduction failure is occurring at the level of the AV node because the escape rhythm is junctional.<span style="mso-spacerun: yes;">&nbsp; </span>Blocks at the AV node level are often temporary. <span style="mso-spacerun: yes;">&nbsp;</span>A block lower than this, from the His Bundle through the common branch of the bundle branches, would produce a ventricular escape rhythm.<span style="mso-spacerun: yes;">&nbsp; </span>The important thing, if you are the patient’s health care provider, is that you assess this rate for adequate perfusion.<span style="mso-spacerun: yes;">&nbsp; </span>A heart rate of 57 is almost always sufficient for good perfusion, and is actually preferable for a patient with an ongoing M.I.<span style="mso-spacerun: yes;">&nbsp; </span>Which would you rather have if you were having an M.I., a heart rate of 57 or 158 bpm?<span style="mso-spacerun: yes;">&nbsp; </span><strong><em>Could we say that this AV block has actually HELPED this particular patient?</em></strong><span style="mso-spacerun: yes;">&nbsp; </span>I will happily leave more advanced discussions of this arrhythmia to our commenters.</p><p class="MsoNormal">The <strong>ST segments are noticeably elevated</strong> in Leads II, III, and aVF.<span style="mso-spacerun: yes;">&nbsp; </span>There is <strong>reciprocal ST depression</strong> in Leads I and aVL, and also in the anterior leads. Lead III has a deep, but not wide <strong>Q wave.</strong> This pushes the frontal axis a bit to the left (I and aVL are taller than II). <span style="mso-spacerun: yes;">&nbsp;</span>The T waves in many leads are “hyperacute”.<span style="mso-spacerun: yes;">&nbsp; </span>That is, they are taller than expected, which is a sign of ischemia.<span style="mso-spacerun: yes;">&nbsp; </span>This patient was confirmed to have a <strong>INFERIOR WALL M.I. </strong><span style="mso-spacerun: yes;">&nbsp;</span>Since the RCA supplies the inferior wall and the AV node in the majority of people, it is not surprising that there is an AV block at the level of the AV node. Also, the posterior wall is supplied by the RCA in most people, and the ST depression in the anterior wall with prominent R waves in the septal leads point to posterior M.I.&nbsp; The much less prominent ST depression in V1, as compared to V2, indicates that the right ventricle is sending a signal to V1 to "elevate", while the posterior wall tells V1 to "depress". This results in an ST segment that is cancelled by opposing forces.&nbsp; This would be a good patient to perform V4Right, V7, V8, and V9 on (16-lead ECG).</p><p class="MsoNormal">This is a good ECG to demonstrate what ST segment elevation looks like in acute M.I., as opposed to other causes of STE.<span style="mso-spacerun: yes;">&nbsp; </span>In M.I., we see certain characteristics:</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]--><span style="mso-spacerun: yes;">&nbsp;</span>The STE is found localized in related leads</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]--><span style="mso-spacerun: yes;">&nbsp;</span>The ST segments tend to be straight or curved upward, rather than the normal convex shape</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]--><span style="mso-spacerun: yes;">&nbsp;</span>There is ST depression is leads that are opposite the elevation (See III and aVL)</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]--><span style="mso-spacerun: yes;">&nbsp;</span>There are accompanying signs of M.I., such as T wave inversion, hyperacute T waves, and pathological Q waves. <span style="mso-spacerun: yes;">&nbsp;</span></p><p class="MsoNormal">This ECG can also serve to start a conversation with students about when it is appropriate to treat bradycardia, and when it is best left alone.</p><p class="MsoNormal">EDIT: Dr. Ken Grauer has written a very informative and thought-provoking comment below. If you would like to hear his thoughts on this ECG in more depth, go to his blog at&nbsp;<a href="https://ecg-interpretation.blogspot.com/2021/12/ecg-blog-268-76-mobitz-i-vs-complete-av.html?m=1">https://ecg-interpretation.blogspot.com/2021/12/ecg-blog-268-76-mobitz-i-vs-complete-av.html?m=1</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/363/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 Inferior-posterior Wall M.I. and AV Dissociation 1/5</option><option value="40">Give Inferior-posterior Wall M.I. and AV Dissociation 2/5</option><option value="60">Give Inferior-posterior Wall M.I. and AV Dissociation 3/5</option><option value="80" selected="selected">Give Inferior-posterior Wall M.I. and AV Dissociation 4/5</option><option value="100">Give Inferior-posterior Wall M.I. and AV Dissociation 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 >56</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-rWxAMk1ORlsdwzva_vqhy_hkVOnqpBEZUvgtMoobqPo" /> <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/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</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 class="field-item odd"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</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/right-ventricular-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right ventricular M.I.</a></div><div class="field-item even"><a href="/ecg/posterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Posterior M.I.</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/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/escape-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Escape rhythm</a></div><div class="field-item even"><a href="/ecg/junctional-escape" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional escape</a></div><div class="field-item odd"><a href="/ecg/right-coronary-artery-occlusion" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right coronary artery occlusion</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%2Finferior-posterior-wall-mi-and-av-dissociation&amp;title=Inferior-posterior%20Wall%20M.I.%20and%20AV%20Dissociation"><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> Mon, 06 Dec 2021 23:59:10 +0000 Dawn 810 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-posterior-wall-mi-and-av-dissociation#comments Ask The Expert https://www.ecgguru.com/expert-review/ask-expert-14 <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 class="MsoNormal" style="margin-bottom: 0in; line-height: 15.0pt; background: white; vertical-align: baseline;"><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in; mso-no-proof: yes;"><span style="mso-spacerun: yes;"><span style="font-family: 'Lucida Sans Unicode', sans-serif;"><span style="font-size: 16px;"><strong>Today's Expert is Dr. Jerry Jones, MD, FACEP, FAAEM</strong></span></span><span style="font-family: Verdana, sans-serif;"><span style="font-size: 9pt;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; </span></span></span></span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: 15.0pt; background: white; vertical-align: baseline;"><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in; mso-no-proof: yes;"><span style="mso-spacerun: yes;"><span style="font-family: Verdana, sans-serif;"><span style="font-size: 9pt;">&nbsp;J</span></span></span></span><span style="font-family: Verdana, sans-serif; font-size: 9pt;">erry W. Jones, MD FACEP FAAEM is a diplomate of the American Board of Emergency Medicine who has practiced internal medicine and emergency medicine for 35 years.&nbsp; &nbsp;&nbsp;<img src="/sites/default/files/pictures/Profile%20photo.jpg" width="96" height="100" style="float: right;" /></span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: 15.0pt; background: white; vertical-align: baseline;"><span style="font-family: Verdana, sans-serif; font-size: 9pt;">Dr. Jones has been on the teaching faculties of the University of Oklahoma and The University of Texas Medical Branch in Galveston. He is a published author who has also been featured in the New York Times and the Annals of Emergency Medicine for his work in the developing field of telemedicine. He is also a Fellow of the American College of Emergency Physicians and a Fellow of the American Academy of Emergency Medicine and, in addition, a member of the European Society of Emergency Medicine.&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal; background: white; vertical-align: baseline;"><span style="font-size: 10.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black;">&nbsp;</span><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">Dr. Jones is the CEO of</span><span><a title="Medicus of Houston Website" href="http://www.medicusofhouston.com/"><span style="font-size: 9.0pt; font-family: 'inherit',serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: #0062a0; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">&nbsp;Medicus of Houston</span></a></span><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">&nbsp;and the principal instructor for the&nbsp;</span><span><a href="https://medicusofhouston.com/"><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: #0062a0; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">Advanced ECG Interpretation Boot Camp and the Advanced Dysrhythmia Boot Camp</span></a></span><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">.&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size: 9pt; font-family: Verdana, sans-serif;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal; background: white; vertical-align: baseline;">&nbsp;</p><p class="MsoNormal"><strong><span style="font-size: 18.0pt; line-height: 107%; color: #00b050;">Question:</span></strong><span style="font-size: 20.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">I teach beginner students. How can I explain the complex subject of “AV Blocks”? <span style="mso-spacerun: yes;">&nbsp;</span>I don’t want to teach incorrect information while trying to simplify the subject.</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal; background: white; vertical-align: baseline;">&nbsp;</p><p class="MsoNormal"><strong><span style="font-size: 18.0pt; line-height: 107%; color: #00b050;">&nbsp;Answer:&nbsp; <a title="AV Blocks article" href="https://www.ecgguru.com/ecg-resource/av-blocks-dr-jerry-jones">AV Blocks Article By Dr. Jerry Jones&nbsp; (click link)</a></span></strong></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal; background: white; vertical-align: baseline;"><a title="AV Blocks article" href="https://www.ecgguru.com/ecg-resource/av-blocks-dr-jerry-jones"><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;"><br /></span></a></p></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-blocks" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AV blocks</a></div><div class="field-item odd"><a href="/ecg/atrio-ventricular-blocks" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrio-ventricular blocks</a></div><div class="field-item even"><a href="/ecg/first-degree-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">First-degree AV block</a></div><div class="field-item odd"><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 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-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete AV block</a></div><div class="field-item even"><a href="/ecg/conduction-system" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Conduction system</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%2Fexpert-review%2Fask-expert-14&amp;title=Ask%20The%20Expert%20"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 20 Dec 2020 18:02:21 +0000 Dawn 795 at https://www.ecgguru.com https://www.ecgguru.com/expert-review/ask-expert-14#comments Complete Heart Block With Impending Ventricular Standstill https://www.ecgguru.com/ecg/complete-heart-block-impending-ventricular-standstill <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-impending-ventricular-standstill"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB118%20CHB.jpg" width="1800" height="756" 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="line-height: normal;">&nbsp;</p><div style="mso-element: comment-list;"><!--[if !supportAnnotations]--><hr class="msocomoff" align="left" size="1" width="33%" /><!--[endif]--></div><p class="MsoNormal" style="line-height: normal;"><strong><span style="color: #00b050;">The Patient</span></strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; This ECG was obtained from a 76-year-old woman who had just lost responsiveness while under care of an EMS crew. This tracing was obtained before a trans-cutaneous pacemaker was applied.</p><div><div><!--[if !supportAnnotations]--><div id="_com_1" class="msocomtxt"><!--[endif]--><!--[if !supportAnnotations]--><a name="_msocom_1"></a><!--[endif]--><p class="MsoNormal" style="line-height: normal;"><strong><span style="color: #00b050;">The ECG</span></strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The most noticeable feature of this ECG is the extremely slow rate. In fact, there are only two QRS complexes visible. The P waves are regular at a rate of about 145 bpm, so the underlying rhythm is sinus tachycardia.&nbsp; NONE of the P waves are conducted, as evidenced by the different “PR intervals” in the two QRS complexes seen.&nbsp; This is complete heart block at it’s most extreme – the QRS complexes represent a very insufficient escape rhythm.&nbsp; A pacemaker is the only immediate treatment for this rhythm. Unfortunately, we don’t know the outcome for this patient.</p><p class="MsoNormal" style="line-height: normal;">It is very difficult to make judgements about the QRS complexes with only two of them, visible in three leads each.&nbsp; The first set show the criteria for left ventricular hypertrophy.&nbsp; The QRS in aVL is 20 mm tall, and anything over 11 mm meets voltage criteria for LVH. &nbsp;In addition, the ST segments have the “strain” pattern, another sign of LVH.&nbsp; The second QRS complexes are not typical of a normal ECG or one with LVH.&nbsp; We cannot vouch for the precordial lead placement.</p><p class="MsoNormal" style="line-height: normal;">There is some disagreement in the literature regarding the naming of the blocks. Some consider “high-grade” to be only second-degree AVB with two or more consecutive non-conducted P waves. Others include third-degree AVB in the “high-grade” category.&nbsp; It can come down to just semantics – the RATE and how the patient responds to the rate is the primary consideration.&nbsp; Classification as to the origin of the block is helpful when determining the best long-term treatment decisions.</p><p class="MsoNormal" style="line-height: normal;">This is a good ECG for teaching the concept of AV dissociation, and how dangerous third-degree AV blocks and high-grade second-degree AV blocks can be.&nbsp;&nbsp;</p><!--[if !supportAnnotations]--></div><!--[endif]--></div></div><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/363/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 Complete Heart Block With Impending Ventricular Standstill 1/5</option><option value="40">Give Complete Heart Block With Impending Ventricular Standstill 2/5</option><option value="60">Give Complete Heart Block With Impending Ventricular Standstill 3/5</option><option value="80" selected="selected">Give Complete Heart Block With Impending Ventricular Standstill 4/5</option><option value="100">Give Complete Heart Block With Impending Ventricular Standstill 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 >6</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-paJR2iLPYNb8-LhxE2Kq2yzsfgAGE8fjfG9OyE1smUo" /> <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-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/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</a></div><div class="field-item odd"><a href="/ecg/impending-ventricular-standstill" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Impending ventricular standstill</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%2Fcomplete-heart-block-impending-ventricular-standstill&amp;title=Complete%20Heart%20Block%20With%20Impending%20Ventricular%20Standstill"><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 Dec 2019 00:02:15 +0000 Dawn 779 at https://www.ecgguru.com https://www.ecgguru.com/ecg/complete-heart-block-impending-ventricular-standstill#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/363/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-O_8gtMIgIklE25RJ40KFqYHEYu-5ZgACwNzAEnMISE0" /> <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_4"> <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 Complete AV Block With Junctional Escape Rhythm https://www.ecgguru.com/ecg/complete-av-block-junctional-escape-rhythm-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/complete-av-block-junctional-escape-rhythm-1"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB117%20CHB%20Junct%20Esc.jpg" width="1800" height="1424" 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"><span style="font-size: 12.0pt; line-height: 107%;">This ECG is from a 78-year-old woman.&nbsp; We do not know any clinical details.</span></p><p class="MsoNormal"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span><span style="font-size: 12pt;">We break from our usual habit of removing the ECG machine’s interpretation of the ECG to serve as a reminder that the computer interpretation can be wrong. </span><span style="font-size: 12pt;">&nbsp;</span><span style="font-size: 12pt;">ECGs should ALWAYS be interpreted by a knowledgeable person.</span><span style="font-size: 12pt;">&nbsp; </span><span style="font-size: 12pt;">The machine interpretation can serve as a reminder, but should not take the place of human interpretation.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Here is what we DO see:&nbsp; There is a normal sinus rhythm present, as evidenced by the regular P waves that do not change their morphology.&nbsp; Some of the P waves are “buried” behind QRS or T waves.&nbsp; The atrial rate is 95 bpm.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The ventricular rhythm, at 40 bpm, is also regular, but is separate from the atrial rhythm.&nbsp; Even though some of the P waves LOOK like they have conducted to produce QRS complexes, they have not.&nbsp; The PRIs are not all the same.&nbsp; Neither do they “progressively prolong”.&nbsp; There is no irregularity of the QRS rhythm or variation in QRS morphology.&nbsp; We see the classic “AV DISSOCIATION” of complete heart block.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">When there is a third-degree AV block with a narrow-QRS escape rhythm, we can assume the block is in the AV node.&nbsp; The junction is the escape focus, producing a narrow-complex rhythm between approximately 40-60 bpm.&nbsp; In this case, the QRS is slightly wide at 112 ms (.11 sec), and the QRS complexes in several leads are fragmented.&nbsp; Some might argue that there is an idioventricular escape mechanism.&nbsp; But, with a normal frontal plane axis, borderline width, &nbsp;and no T wave inversions, the rhythm looks more supraventricular.&nbsp; The R wave progresson on the precordial leads shows a persistently negative QRS with late transition in V5.&nbsp; The QRS complexes in V1 and V2 appear to have pathological Q waves.&nbsp; When R wave progression is not normal, we should also consider electrode misplacement.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The immediate concern for patients with AV dissociation and escape rhythms is the RATE.&nbsp;</span><span style="font-size: 12pt;">If the rate becomes very slow, it can have deleterious effects on the patient’s hemodynamic status.</span><span style="font-size: 12pt;">&nbsp; </span><span style="font-size: 12pt;">The rate can usually be quickly enhanced with the use of a pacemaker – either temporary trans-venous pacing or trans-cutaneous pacing.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Lastly, the ST segments over this entire ECG are flat and horizontal, a possible sign of ischemic disease.&nbsp; It is not localized to a specific part of the heart or coronary artery’s area.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">&nbsp;</span></p><p>&nbsp;</p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">&nbsp;</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/363/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 Complete AV Block With Junctional Escape Rhythm 1/5</option><option value="40">Give Complete AV Block With Junctional Escape Rhythm 2/5</option><option value="60">Give Complete AV Block With Junctional Escape Rhythm 3/5</option><option value="80" selected="selected">Give Complete AV Block With Junctional Escape Rhythm 4/5</option><option value="100">Give Complete AV Block With Junctional Escape Rhythm 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4</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--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-HxRaIjfPPQD8x08bJNGutLXJy9RxMTmg2KbLIPeR04M" /> <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/complete-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete AV block</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/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/incorrect-machine-interpretation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Incorrect machine interpretation</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></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%2Fcomplete-av-block-junctional-escape-rhythm-1&amp;title=%20Complete%20AV%20Block%20With%20Junctional%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> Thu, 27 Oct 2016 20:29:42 +0000 Dawn 713 at https://www.ecgguru.com https://www.ecgguru.com/ecg/complete-av-block-junctional-escape-rhythm-1#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/363/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 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--5" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-kR5kluzp5Dp4lUgcq8hgLh8mTRKZgbdy6OAWE8tedOM" /> <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_6"> <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/363/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: 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--6" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-5EG-eIrmQi3V83gYzfYjiisbPRy6KqWQEB9MT-wJ1Nk" /> <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_7"> <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 Complete AV Block With Junctional Escape Rhythm https://www.ecgguru.com/ecg/complete-av-block-junctional-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/complete-av-block-junctional-escape-rhythm-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB113_0.jpg" width="1800" height="891" 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 ECG was taken from a 90-year-old woman. &nbsp;We have no other history, unfortunately. &nbsp;It is a good example of a sinus rhythm with complete AV block, also called third-degree AV block.</p><p>The defining characteristics of this rhythm include: &nbsp; 1) an underlying rhythm that is regular and with a physiological rate. &nbsp;In other words, the P waves are not so fast that they would not be expected to conduct one-to-one. &nbsp;2) &nbsp;a second rhythm of regular QRS complexes that is unrelated to the P waves.</p><p>Occasionally, a P wave may occur before a QRS and appear to have a PR interval. &nbsp;This is just a chance meeting, as both rhythms (P waves and QRS complexes) are regular AT DIFFERENT RATES, so we would expect them to occur near each other from time to time. &nbsp;NONE of the P waves are being conducted to the ventricles to produce QRS complexes. This is a good ECG to demonstrate "marching out" the P waves to see that they are very regular, even though some are hidden in the QRS, ST segment, or T waves.</p><p>In this case, the "escape rhythm" occurs from the AV junction. &nbsp;The AV junctional pacemakers are "set" at a rate of about 40 - 60 beats per minute. &nbsp;Normally, the sinus rhythm arrives in the AV junction faster than that, depolarizing the junctional pacemakers and preventing them from firing spontaneously. &nbsp;In complete AV block, the atrial impulse never arrives, so the junctional pacemaker is free to "escape" and become the primary pacemaker of the heart. &nbsp;We recognize this rhythm as junctional because the QRS complexes are narrow, and the rate is around 40 bpm. &nbsp;Knowing that the escape rhythm is from the junction tells us that the AV block is in the AV node. &nbsp;The AV junction is the first available pacemaker below the block. &nbsp;Had the complete AV block been lower, in the bundle branches, the QRS would have come from the ventricles and would have been wide and slower.</p><p>In very general terms, this "supra-Hisian" type of AV block is preferable to a "sub-Hisian" block. &nbsp;The rate is faster, and the QRS complexes narrow, both conditions causing a better cardiac output than wide QRS complexes and extremely slow rates. &nbsp;However, the effect of the block on the patient has a lot to do with the cause of the block and the symptoms the slow rate cause. &nbsp;Emergency treatment of the rate may be necessary if it causes a drop in blood pressure and perfusion. &nbsp;Some patients with this type of block will need a permanent implanted pacemaker, but not all.&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/363/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 Complete AV Block With Junctional Escape Rhythm 1/5</option><option value="40">Give Complete AV Block With Junctional Escape Rhythm 2/5</option><option value="60" selected="selected">Give Complete AV Block With Junctional Escape Rhythm 3/5</option><option value="80">Give Complete AV Block With Junctional Escape Rhythm 4/5</option><option value="100">Give Complete AV Block With Junctional Escape Rhythm 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 >2</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-iKnTtj7m5l-KlTynn0zyfh5_VB0lR1RU6Y1yGFUSgB4" /> <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/complete-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete AV 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-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional rhythm</a></div><div class="field-item even"><a href="/ecg/junctional-escape-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional escape rhythm</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%2Fcomplete-av-block-junctional-escape-rhythm-0&amp;title=Complete%20AV%20Block%20With%20Junctional%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> Fri, 04 Sep 2015 05:02:59 +0000 Dawn 660 at https://www.ecgguru.com https://www.ecgguru.com/ecg/complete-av-block-junctional-escape-rhythm-0#comments ECG Basics: Atrial Fibrillation With Complete AV Block https://www.ecgguru.com/ecg/ecg-basics-atrial-fibrillation-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/ecg-basics-atrial-fibrillation-complete-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/151%20Atrial%20fib%20with%20CHB.jpg" width="1553" height="219" 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-family: Verdana, Helvetica, Arial, sans-serif; font-size: 13px; line-height: 17.7272720336914px;">This patient has an underlying atrial fibrillation with complete heart block and an idioventricular escape rhythm.&nbsp; She was treated successfully with a permanent implanted pacemaker.</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/363/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 ECG Basics: Atrial Fibrillation With Complete AV Block 1/5</option><option value="40">Give ECG Basics: Atrial Fibrillation With Complete AV Block 2/5</option><option value="60">Give ECG Basics: Atrial Fibrillation With Complete AV Block 3/5</option><option value="80">Give ECG Basics: Atrial Fibrillation With Complete AV Block 4/5</option><option value="100" selected="selected">Give ECG Basics: Atrial Fibrillation With Complete AV Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.4</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--8" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-NzKrZghBX_kgr8pXmclqLmbTQXyvIg9BbanfzuHSsMg" /> <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/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</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 class="field-item odd"><a href="/ecg/atrial-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial fibrillation</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></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%2Fecg-basics-atrial-fibrillation-complete-av-block&amp;title=ECG%20Basics%3A%20Atrial%20Fibrillation%20With%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> Tue, 19 May 2015 17:41:54 +0000 Dawn 640 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-atrial-fibrillation-complete-av-block#comments Complete AV Block https://www.ecgguru.com/ecg/complete-av-block-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/complete-av-block-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB110%20B_0.jpg" width="1800" height="644" alt="" /></a></div><div class="field-item odd"><a href="/ecg/complete-av-block-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB110%20B%20w%20markup.jpg" width="1800" height="644" 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 ECG is from an 84-year-old man who experienced dizziness and a fall. &nbsp;He was not injured in the fall. &nbsp;In this ECG, we can clearly see regular P waves at about 110 per minute. &nbsp;We also see wide QRS complexes at about 52 per minute. &nbsp;There is AV &nbsp;dissociation - there are no regular PR intervals, or even progressively-prolonging PR intervals. &nbsp;The atrial and the ventricles are beating to separate rhythms. &nbsp;What is interesting about this rhythm is the origin of the escape rhythm. &nbsp;The wide complex suggests a ventricular focus and the rate suggests supraventricular origin. &nbsp;Near the end of the ECG, the escape rhythm either fails or slows significantly. &nbsp;To see the next 12-lead ECG for this patient, go to this<a title="110 C CHB" href="http://ecgguru.com/ecg/third-degree-av-block"> LINK.</a></p><p>The second ECG makes it more clear that this is an idioventricular escape rhythm, but the morphology of the QRS complexes suggested that, even in the first ECG when the rate was faster. &nbsp;There are several clues that this is probably ventricular, including a very "backward" axis with aVR being upright and II, III, and aVF all being negative. &nbsp;Also, V6 is negative, and there is nearly precordial concordance: &nbsp;all except V1 are negative. &nbsp;The morphology of the QRS does not fit a diagnosis of either left bundle branch block OR right bundle branch block. &nbsp;The evidence points to a ventricular origin for this escape rhythm, and the patient quickly goes on to slow down severely. &nbsp;Ventricular escape rhythm strongly suggests a sub-Hisian location for the block, and they tend to be more life-threatening than supra-Hisian blocks.</p><p>The take-home clinical lesson here is to BE PREPARED for worsening of the rate whenever AV block is present, especially high-grade AV block or sub-Hisian block. &nbsp;This ECG is a very good one for teaching students to "march out" P waves, and find "hidden" P waves. &nbsp;We have included a marked copy of this ECG to indicate those P waves.</p><p>Thanks to Sebastian Garay for donating these ECGs.</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/363/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 Complete AV Block 1/5</option><option value="40">Give Complete AV Block 2/5</option><option value="60">Give Complete AV Block 3/5</option><option value="80" selected="selected">Give Complete AV Block 4/5</option><option value="100">Give Complete AV 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--9" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-To4wk6XzQTJzHtBvPUHzkVvmIXwk9gHR-a-p-Cu44hc" /> <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-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete AV block</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/av-dissociation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AV dissociation</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 class="field-item odd"><a href="/ecg/ventricular-standstill" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular standstill</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%2Fcomplete-av-block-0&amp;title=Complete%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> Tue, 16 Sep 2014 20:26:50 +0000 Dawn 599 at https://www.ecgguru.com https://www.ecgguru.com/ecg/complete-av-block-0#comments