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Jason's Blog: ECG Challenge of the Week for Oct. 21-28, 2012

Submitted by jer5150 on Sun, 10/21/2012 - 14:34

No clinical patient data available for this 12-lead ECG.

What does this tracing show? Choose the correct answer from the list below.

(1.) Sinus bradycardia with atrial bigeminy; conducted APBs; prominent U-waves; RBBB
(2.) Sinus rhythm with 3:2 and 2:1 Type II AV block; RBBB
(3.) Sinus rhythm with atrial bigeminy; both conducted and nonconducted APBs; RBBB

Acronyms:
APBs = atrial premature beats
RBBB = right bundle-branch block

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Anterior Wall M.I. With Bifascicular Block

Submitted by Dawn on Fri, 10/19/2012 - 20:46

This is a good example of acute anterior wall M.I., with ST elevation in V1 through V6, as well as in Leads I and aVL. The extensive distribution of ST segment elevations across the anterior and high lateral walls indicates a proximal LAD artery occlusion. In addition, this ECG shows right bundle branch block, with a QRS width of 144 ms (.14 sec.) and an rsR' pattern in V1. There is also a wide s wave in Lead I which is partly obscurred in V6 by the ST elevation. The right axis deviation (98 degrees) suggests a left posterior fascicular block which, when coupled with the RBBB, is a bi-fascicular block. P waves are difficult to see. Do you think they are found at the end of the QRS complexes, representing a long first-degree AVB? Look at leads V3 through V6 for clues.

Please feel free to add your comments below. The more "gurus" the better.

A good ECG to teach your students that a patient facing a life-threatening emergency may have a "normal" rate and regular rhythm. There is something in this ECG for beginners through advanced students.

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Sinus Rhythm With Non-Conducted Atrial Bigeminy

Submitted by Dawn on Tue, 06/26/2012 - 20:02

Jason's Blog: ECG Challenge of the Week, 6-8-12 INTERPRETATION:

1) In first half of strip: Normal sinus rhythm (rate = 100/min) with . . .

2) . . . bifascicular block—right bundle-branch block plus left anterior hemiblock

(RBBB + LAHB), left axis deviation (LAD) at -57 degrees.

3) In second half of strip: Sinus rhythm interrupted by a run of nonconducted atrial bigeminy (arrows (↓); see laddergram).

Jason E. Roediger, CCT, CRAT

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Atrial Fib, Bifascicular Block, Pacemaker

Submitted by Dawn on Tue, 04/10/2012 - 12:53

Lots of information in this ECG! The underlying rhythm is atrial fibrillation with a controlled rate. The QRS is .12 seconds in duration, with an rSR' pattern in V1 and a wide s wave in Leads I and V6, indicating right bundle branch block. In addition, the axis is leftward - Leads I and aVL are upright and Leads II, III, and aVF are negative. There is no other obvious reason for the left axis shift, and therefore, the diagnosis by exclusion is left anterior fascicular block. RBBB and LAFB often appear together, as the right bundle branch and the anterior fascicle of the left bundle share the same blood supply from the left coronary artery. ALSO, this patient has a right ventricular pacemaker, and is pacing appropriately when the atrial fib slows. Pacer spikes are not readily seen, but the width of the QRS, the axis of the wide QRS complexes (left), and the timing (after a pause) all support the paced rhythm diagnosis. V5 and V6 actually show a very tiny hint of a spike. The T wave inversions seen in the upright leads are common with RBBB, and are usually considered normal in this setting.

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Atrial Flutter With 1:1 Conduction and Rate-dependent Right Bundle Branch Block

Submitted by Dawn on Mon, 03/19/2012 - 19:40

The first ECG is from an active, otherwise healthy 66-year-old man who experienced a sudden onset of symptomatic tachycardia. He presented to the Emergency Dept. feeling (understandably) very anxious, with poor perfusion to his skin, chest discomfort, and palpitations. As the ED staff prepared to electrically cardiovert him, he spontaneously converted to normal sinus rhythm at a rate of 93 / min. and a QRS duration of 90 ms.

After a normal diagnostic cardiac cath, he was sent to the EP lab and the circuit responsible for this rhythm was successfully ablated. He was discharged in good condition the next day.

This is a good ECG for all levels of students. For beginners, it shows that atrial flutter is one of the rhythms we call "SVT", and it does not always conduct in a variable rate, or a rate that allows "sawtooth" P waves to show easily. You can show them that the "sawtooth" pattern, brought about by P waves that are 250 - 350 per minute, is still there if one ignores the QRS complexes for a moment. This is a great ECG for discussions of rate and cardiac output, and making decisions regarding treatment based on the patient's hemodynamic condition. For more advanced students, this ECG can lead to a discussion of the accessory pathways and re-entrant pathways that cause rapid rhythms. For RBBB criteria, click HERE.

The second ECG shows the same patient after spontaneous conversion to sinus rhythm. The bundle branch block has disappeared, as it was rate-dependent.