ECG Guru - Instructor Resources - PACs https://www.ecgguru.com/ecg/pacs en Right Bundle Branch Block and More https://www.ecgguru.com/ecg/right-bundle-branch-block-and-more <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/right-bundle-branch-block-and-more"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/SR%20w%20PACs%2011.43.jpg" width="1800" height="663" alt="" /></a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-and-more"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Leads%2013%2C%2014%2C%2015_0.jpg" width="1800" height="689" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-tab-count: 1;">&nbsp;&nbsp;&nbsp; </span>These tracings are taken from a 75-year-old man who became weak while playing golf on a very hot day.<span style="mso-spacerun: yes;">&nbsp; </span>He was pale and diaphoretic.<span style="mso-spacerun: yes;">&nbsp; </span>He was hypotensive, but we do not know his BP reading. He denies chest pain or discomfort. The patient reported a history of lung cancer and hypertension. We have no other history, and unfortunately, no follow-up information.</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">ECG Number 1: </span></strong><strong><span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-tab-count: 1;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></strong><span style="font-size: 12.0pt; line-height: 107%;">The first ECG shows the standard 12 leads.<span style="mso-spacerun: yes;">&nbsp; </span>The rhythm is sinus with frequent appearances of PAC couplets.<span style="mso-spacerun: yes;">&nbsp; </span>The sinus rate varies slightly from about 76 bpm to 68 bpm, tending to slow a bit after the premature atrial contractions.<span style="mso-spacerun: yes;">&nbsp; </span>There is a right bundle branch block, and the QRS duration is about .12 seconds (120 ms). The PR interval is slightly log at 223 ms.<span style="mso-spacerun: yes;">&nbsp; </span>We do not know what medications the patient is on, and we do not have an older ECG for comparison.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">There are some interesting, if subtle, changes worth mentioning.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS complexes in most leads are fragmented.<span style="mso-spacerun: yes;">&nbsp; </span>That is, they have notching in the terminal S or R waves that is not due to the bundle branch block. This can be a sign of scarring, and can also be considered an equivalent to a pathological Q wave.<span style="mso-spacerun: yes;">&nbsp; </span>Speaking of pathological Q waves, they are seen in the inferior leads, II, III, and aVF.<span style="mso-spacerun: yes;">&nbsp; </span>There are also prominent, though not large Q waves in V4 through V6, leads which normally do not have them. All this points to scarring and possibly long-term coronary artery disease, with possible old M.I.<span style="mso-spacerun: yes;">&nbsp; </span>In addition, the ST segments are not entirely normal.<span style="mso-spacerun: yes;">&nbsp; </span>There is ST depression in the inferior and low lateral leads, a little ST elevation in aVL.<span style="mso-spacerun: yes;">&nbsp; </span>Also, the SHAPES of the ST segments tend to be straight throughout the ECG, instead of the usual curved (concave up) appearance. </span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">ECG Number 2:<span style="mso-tab-count: 1;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">The second ECG was obtained with three additional leads, to search for ST elevation that might have been missed by the standard 12 leads.<span style="mso-spacerun: yes;">&nbsp; </span>V4, Right has been added in place of V4.<span style="mso-spacerun: yes;">&nbsp; </span>V8 and V9 have been added to the V5 and V6 positions on the print out.<span style="mso-spacerun: yes;">&nbsp; </span>V4R shows us a pathological Q wave and fragmentation.<span style="mso-spacerun: yes;">&nbsp; </span>The posterior leads do, too, and the ST segments are very flat and slightly elevated.</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">Conclusion: <span style="mso-spacerun: yes;">&nbsp;</span></span></strong><span style="font-size: 12.0pt; line-height: 107%;">Without further evaluation of the patient, and comparison with previous ECGs, it would be very difficult to assign significance to these changes.<span style="mso-spacerun: yes;">&nbsp; </span>Because of his symptoms, he was transported by EMS to a hospital.<span style="mso-spacerun: yes;">&nbsp; </span>For teachers, this is a good example of PAC couplets for your beginner students, and a chance to discuss QRS fragmentation, pathological Q waves, and ST segment shape with your more advanced students.<span style="mso-spacerun: yes;">&nbsp; </span>Also, the value of additional leads to rule out ST elevation M.I. should be emphasized.</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/677/feed" method="post" id="fivestar-custom-widget" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--2" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Right Bundle Branch Block and More 1/5</option><option value="40">Give Right Bundle Branch Block and More 2/5</option><option value="60">Give Right Bundle Branch Block and More 3/5</option><option value="80" selected="selected">Give Right Bundle Branch Block and More 4/5</option><option value="100">Give Right Bundle Branch Block and More 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.4</span></span> <span class="total-votes">(<span >43</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-pheEbp-N1nG39Nx0gPMIS8RebGcmGyjrutZ_r2fimBs" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item odd"><a href="/ecg/rbbb" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">RBBB</a></div><div class="field-item even"><a href="/ecg/left-posterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior hemiblock</a></div><div class="field-item odd"><a href="/ecg/qrs-fragmentation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">QRS fragmentation</a></div><div class="field-item even"><a href="/ecg/pacs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PACs</a></div><div class="field-item odd"><a href="/ecg/couplets" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Couplets</a></div><div class="field-item even"><a href="/ecg/st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST changes</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fright-bundle-branch-block-and-more&amp;title=%20Right%20Bundle%20Branch%20Block%20and%20More"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Sat, 22 Aug 2020 21:33:52 +0000 Dawn 788 at https://www.ecgguru.com https://www.ecgguru.com/ecg/right-bundle-branch-block-and-more#comments Inferior-lateral M.I. With QRS Fragmentation https://www.ecgguru.com/ecg/inferior-lateral-mi-qrs-fragmentation <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-lateral-mi-qrs-fragmentation"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW120%20fQRS%20V4R%20ECG6.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 class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">SUBTLE ST CHANGES&nbsp;&nbsp; </span></strong><span style="font-size: 12.0pt; line-height: 107%;">This ECG was obtained from an 87-year-old man who was experiencing chest pain.&nbsp; Due to the subtle ST elevation in Leads II, III, aVF, V<sub>5</sub>, and V<sub>6</sub>, (inferior- lateral walls) the ECG was transmitted to the hospital by the EMS crew, and the cath lab was activated.&nbsp; The patient denied previous cardiac history.</span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">In addition to the subtle ST elevation, there is ST depression in V<sub>1</sub> through V<sub>4</sub>, which represents a reciprocal view of the injury in the inferior-posterior-lateral wall.&nbsp; Because the anterior wall is superior in its position in the chest, it is opposite the inferior/posterior wall, and can show ST depression when the inferior-posterior area has ST elevation. This ECG was the 6<sup>th</sup> one done during this EMS call.&nbsp; Prior to this one, the ST segments were elevated less than 1 mm. &nbsp;This is a good example of the value of repeat ECGs during an acute event.&nbsp;</span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">RIGHT VENTRICULAR M.I.?&nbsp;&nbsp;&nbsp;&nbsp; </span></strong><span style="font-size: 12.0pt; line-height: 107%;">This ECG was done with V<sub>4</sub> placed on the right side, to check for right ventricular M.I., which is a protocol for this EMS agency. When the right coronary artery is the culprit artery (about 80% of IWMIs), RVMI is likely.&nbsp; In RVMI, we would usually see reciprocal ST depression in Leads I and aVL, but the STE is very subtle here, so the depression would likely be also.&nbsp; When the culprit artery is the left circumflex artery (&lt;20%), lateral lead ST elevation is more likely, as we see here in V<sub>5</sub> and V<sub>6</sub>.</span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">WHAT ABOUT RHYTHM?</span></strong><span style="font-size: 12.0pt; line-height: 107%;">&nbsp;&nbsp;&nbsp; &nbsp;The rhythm is sinus with PACs.&nbsp; PACs are considered to be benign in most situations, but in a patient with acute M.I., any dysrhythmia can be concerning. The QT interval, measured as QTc (corrected to a heart rate of 60 bpm), is slightly prolonged at .458 seconds (458 ms).&nbsp; Over .440 seconds is considered prolonged in men, and over .500 sec. places the patient at increased risk of developing torsades de pointes.&nbsp; CAD and myocardial ischemia can lead to this modest increase in QTc.</span></p><p class="MsoNormal"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span><strong style="font-size: 13.008px; line-height: 1.538em;"><span style="font-size: 12.0pt; line-height: 107%;">WHY DO SOME OF THE QRS COMPLEXES HAVE “NOTCHES”?&nbsp;&nbsp;&nbsp;&nbsp; </span></strong><span style="font-size: 12pt; line-height: 107%;">Of greater importance is the <a href="http://ncbi.nlm.nih.gov/pmc/articles/PMC3443879/#!po=22.9167">fragmentation of the QRS</a> complexes (fQRS) we see here. Notice the extra notches after the R waves in Leads II and aVF, the notch after the S wave in Lead III, V<sub>5</sub> and V<sub>6</sub>.&nbsp; This “fragmentation” is a sign of a myocardial scar, and is similar to finding a pathological Q wave on the ECG.&nbsp; In a patient with a history of coronary artery disease, fQRS is often associated with ventricular dysfunction and congestive heart failure. It can indicate that conditions are favorable for the formation of re-entrant ventricular tachycardia. Fragmented QRS is more likely to appear in the setting of STEMI and NSTEMI, and less likely in unstable angina.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The patient survived post-angioplasty, and we do not know his eventual outcome.&nbsp; Our thanks to William Bond for providing this ECG.</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/677/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 Inferior-lateral M.I. With QRS Fragmentation 1/5</option><option value="40">Give Inferior-lateral M.I. With QRS Fragmentation 2/5</option><option value="60">Give Inferior-lateral M.I. With QRS Fragmentation 3/5</option><option value="80">Give Inferior-lateral M.I. With QRS Fragmentation 4/5</option><option value="100" selected="selected">Give Inferior-lateral M.I. With QRS Fragmentation 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 >5</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-I2quv9cnHjiL4bmqvB6jcEfCK2kjo8zZkXr1VVubxys" /> <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/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item even"><a href="/ecg/inferior-posterior-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-posterior M.I.</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/qrs-fragmentation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">QRS fragmentation</a></div><div class="field-item odd"><a href="/ecg/pacs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PACs</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></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%2Finferior-lateral-mi-qrs-fragmentation&amp;title=%20Inferior-lateral%20M.I.%20With%20QRS%20Fragmentation"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 14 Aug 2016 05:33:04 +0000 Dawn 707 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-lateral-mi-qrs-fragmentation#comments ECG Basics: Sinus Rhythm With Atrial Bigeminy https://www.ecgguru.com/ecg/ecg-basics-sinus-rhythm-atrial-bigeminy <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-sinus-rhythm-atrial-bigeminy"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/107%20Sinus%20Rhythm%20with%20Atrial%20Bigeminy.jpg" width="1800" height="295" 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 is a normal sinus rhythm with atrial bigeminy, a term meaning that every other beat is a PAC. &nbsp;If you look carefully, you can see slight differences in the sinus P waves and the atrial (premature) P waves. &nbsp;The PACs penetrate and reset the sinus node, causing what looks like a delay after the PAC. &nbsp;It is often just a return to the normal P to P interval, or nearly so. &nbsp;If you teach basic students in a clinical setting, they will learn from palpating the peripheral pulse and feeling the pattern of bigeminal beats. Sometimes, the premature beat feels much weaker due to less filling time available to the ventricles. &nbsp;Atrial bigeminy can have very benign causes, such as increased caffeine intake, or it can have more complex causes such as advanced heart disease or conduction blocks. &nbsp;In some patients, atrial bigeminy, or any PACs, can be a precursor to more serious atrial dysrhythmias, such as atrial fibrillation.</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/677/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 ECG Basics: Sinus Rhythm With Atrial Bigeminy 1/5</option><option value="40">Give ECG Basics: Sinus Rhythm With Atrial Bigeminy 2/5</option><option value="60">Give ECG Basics: Sinus Rhythm With Atrial Bigeminy 3/5</option><option value="80" selected="selected">Give ECG Basics: Sinus Rhythm With Atrial Bigeminy 4/5</option><option value="100">Give ECG Basics: Sinus Rhythm With Atrial Bigeminy 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.4</span></span> <span class="total-votes">(<span >8</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-lpS8JEGy5AcrBNn7hZEmRrlG7juEyoNrk6rzmcVJQLo" /> <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/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</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/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item odd"><a href="/ecg/sinus-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus rhythm</a></div><div class="field-item even"><a href="/ecg/atrial-bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial bigeminy</a></div><div class="field-item odd"><a href="/ecg/pacs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PACs</a></div><div class="field-item even"><a href="/ecg/premature-atrial-contractions" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Premature atrial contractions</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%2Fecg-basics-sinus-rhythm-atrial-bigeminy&amp;title=ECG%20Basics%3A%20%20Sinus%20Rhythm%20With%20Atrial%20Bigeminy"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 30 Jun 2013 07:22:29 +0000 Dawn 459 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-sinus-rhythm-atrial-bigeminy#comments