Dawn's picture
Submitted by Dawn on Sun, 03/10/2013 - 01:13

This is a good ECG for demonstrating sinus brady and first-degree AV block. It shows the sinus node in the process of slowing down. For your more advanced students, there is left axis deviation due to left anterior fascicular block (left anterior hemiblock). The ST segments are flat, suggesting coronary artery disease. The fourth (bottom) channel is a good rhythm strip. Just crop the image. Please refer to Dr. Grauer's interesting post on teaching hemiblocks on our Ask The Expert page.

Related Terms: 
Sinus bradycardia
First-degree AV block
Left anterior fascicular block
Hemiblock
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ekgpress@mac.com's picture

Submitted by [email protected] on Sun, 03/10/2013 - 14:39

As one who teaches ECG/Arrhythmia interpretation - I often prefer not knowing the clinical scenario associated with a given tracing - because I can then make up my own scenarios to best fit my teaching goals for the situation at hand. So I'm happy Dawn omitted any clinical information on this tracing.

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There are multiple instructive aspects to this tracing. Starting with the Rhythm: Address your attention first solely to the long Lead II Rhythm Strip at the bottom of the tracing. 

  • The QRS complex is narrow.
  • The rhythm is verly slow and irregular. The rate toward the middle of the tracing is in the 20's/minute.
  • P wave morphology is difficult to make out in this lead II rhythm strip due to the very small amplitude of sinus P waves - AND - the lead standardization mark (at the very beginning of the tracing) appears to cut off the initial part of the P wave before beat #1 - BUT - I believe the PR interval for beat #1 would have been LONGER than the PR interval preceding beat #2.
  • The presence of marked sinus bradycardia with great variability in regularity - AND - with changing PR intervals of beats that presumably conduct to me strongly suggests a vagotonic effect. (Please see my ECG Blog #61 for more on Vagotonic AV Block).
So - putting my "instructor hat" back on - I might ask, "What you would do if you saw this rhythm in an otherwise healthy adult who was having an episode of prolonged vomiting?" - with answer being "vagotonic effect" that will probably resolve once the vomiting stops. In contrast - IF the scenario was an older patient with syncopal episodes - the patient almost certainly will end up with a pacemaker ..... (though helpful to keep in mind that if this patient was acutely symptomatic - treatment with Atropine might be very helpful).
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Assuming the patient was middle-aged or older - Let's now address Other Findings on this 12-lead ECG:
  • There is LAHB (Left Anterior HemiBlock) - as per Dawn, given marked LAD that is clearly more than -30 degrees (Click AXIS-HEMIBLOCKS for more on this subject).  
  • There is voltage for LVH (Left Ventricular Hypertrophy) - given a very tall R wave in lead aVL that is >12mm (albeit accuracy for the diagnosis of LVH based on lead aVL amplitude is less reliable in the setting of LAHB that alters the sequence of LV depolarization).
  • There are small, narrow q waves in leads I,aVL (which are likely to be normal septal q waves).
  • Transition is delayed in the precordial leads (it is not until between leads V5-to-V6 that the R wave attains the amplitude of the S wave) - and persistent S waves are seen in lateral precordial leads (normally one does not see any S wave at all in leads V5,V6). Persistent precordial S waves can be seen in patients with chronic pulmonary disease - AND - also in those with chest wall/body habitus variations. In addition - transition may be delayed as a result of LAHB (since the posterior hemifascicle depolarizes first with LAHB - thereby potentially reducing anterior forces ... ) - albeit usually reduced R wave amplitude from LAHB does not persist to the lateral precordial leads.
  • The MOST CONCERNING FINDING however - is the shape of the ST segment for the single beat we see in lead V2 PLUS the prominent T wave peaking we see in multiple leads (leads I, II, V2-thru-V6). Atlhough I definitely would check a serum K+ value - I doubt this is hyperkalemia since the base of these T waves is not as narrow as is usually seen with hyperkalemia (Click Hyper-K for more on this subject). 
  • Instead - I would be most concerned with ischemia that may be acute given the shape of the ST-T waves I see. This is especially true given the excessively slow rate. WHAT TO DO would depend on the clinical situation. As stated - IF the patient was otherwise healthy and just had prolonged vomiting - everything might be secondary to increased vagotonia (and might resolve once the vomiting stopped). But I suspect the ST-T waves that I'm seeing here represent more than that - so additional evaluation will probably be in order. 
Another GREAT Teaching Tracing by Dawn!

Ken Grauer, MD  www.kg-ekgpress.com   [email protected] 

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