ECG Guru - Instructor Resources - Left posterior hemiblock https://www.ecgguru.com/ecg/left-posterior-hemiblock en Marked Bradycardia With Bifascicular Block https://www.ecgguru.com/ecg/marked-bradycardia-bifascicular-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/marked-bradycardia-bifascicular-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Junctional%20RBBB%20LPH.jpg" width="1800" height="1257" 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%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp; </span></span><span style="font-size: 12.0pt; line-height: 107%;">This ECG was taken from an elderly woman. Unfortunately, we do not know any details about the case.<span style="mso-spacerun: yes;">&nbsp; </span>That acknowledged, there are many interesting aspects to this ECG.</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The ECG:</span></strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 12.0pt; line-height: 107%;">The first thing we notice is the severe <strong>bradycardia</strong> – almost certain to be symptomatic.<span style="mso-spacerun: yes;">&nbsp; </span>The rate is 32 bpm and the rhythm is regular.<span style="mso-spacerun: yes;">&nbsp; </span>There are no P waves.<span style="mso-spacerun: yes;">&nbsp; </span>This is a <strong>junctional rhythm</strong>, slightly slower than expected from junctional escape.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The QRS shows the presence of <strong>right bundle branch block</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>Each QRS on the ECG starts as a narrow complex, but then adds an “extra” wave onto the end – the delay caused by the right ventricle depolarizing late.<span style="mso-spacerun: yes;">&nbsp; </span>The terminal delay is very noticeable in V1 as an R’ wave, and in Leads I and V6 as a small, wide s wave.<span style="mso-spacerun: yes;">&nbsp; </span>There is right axis deviation, so the diagnosis of <strong>bifascicular block</strong> (RBBB and left posterior fascicular block) can be made.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">V2 through V6 show <strong>fragmentation of the QRS </strong>complexes and a loss of voltage and R wave progression.<span style="mso-spacerun: yes;">&nbsp; </span>This points to anterior wall M.I. We can’t know the age of the M.I. without clinical correlation, but the ST segments in those leads are very <strong>flat,</strong> with uniformly symmetrical <strong>inverted T waves</strong> all the way to V6.<span style="mso-spacerun: yes;">&nbsp; </span>All of these signs indicate recent injury.<span style="mso-spacerun: yes;">&nbsp; </span>An anterior M.I. can cause the bifascicular block we are seeing, since the bundle branches begin in the septum.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Our patient has a host of <strong>conduction system problems</strong>:<span style="mso-spacerun: yes;">&nbsp; </span>there is no sign of sinus node activity, the junctional escape rhythm is slow even for the junction, there is a right bundle branch block, and the left posterior fascicle is blocked. <span style="mso-spacerun: yes;">&nbsp;</span>Many diseases can cause these conduction system failures, including M.I. as well as diseases causing inflammation and fibrosis of tissues. Finding the underlying cause(s) of all these abnormalities is very important, but the FIRST consideration should be protecting perfusion by insuring an adequate rate.<span style="mso-spacerun: yes;">&nbsp; </span>This patient is certainly a candidate for a pacemaker, with her bradycardia and the fact that she is living with only one main fascicle in her bundle branches (the anterior-superior fascicle).</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/343/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 Marked Bradycardia With Bifascicular Block 1/5</option><option value="40">Give Marked Bradycardia With Bifascicular Block 2/5</option><option value="60">Give Marked Bradycardia With Bifascicular Block 3/5</option><option value="80" selected="selected">Give Marked Bradycardia With Bifascicular Block 4/5</option><option value="100">Give Marked Bradycardia With Bifascicular Block 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 >78</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-fMBbfZ-QblX7EKNq7qGIMUJ0zO1AjH9RUH2aDmLmH3Y" /> <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/bifascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bifascicular block</a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item even"><a href="/ecg/left-posterior-fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior fascicular block</a></div><div class="field-item odd"><a href="/ecg/left-posterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior hemiblock</a></div><div class="field-item even"><a href="/ecg/junctional-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional rhythm</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/st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST changes</a></div><div class="field-item odd"><a href="/ecg/anterior-wall-mi-5" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior wall M.I.</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%2Fmarked-bradycardia-bifascicular-block&amp;title=Marked%20Bradycardia%20With%20Bifascicular%20Block"><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> Sun, 10 Jul 2022 20:08:14 +0000 Dawn 817 at https://www.ecgguru.com https://www.ecgguru.com/ecg/marked-bradycardia-bifascicular-block#comments 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/343/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 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--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-AtEgA-yIoXdl3L1BYrLHtEGql4lCMvTepcH8gz352YY" /> <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_2"> <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> </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 Tachycardia In An Unresponsive Patient https://www.ecgguru.com/ecg/tachycardia-unresponsive-patient <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/tachycardia-unresponsive-patient"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Tachycardia%20and%20Hyperkalemia.jpg" width="1800" height="713" 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 style="mso-bidi-font-weight: normal;">&nbsp;</strong><strong style="font-size: 13.008px;"><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">The Patient</span></strong><span style="font-size: 10pt; line-height: 107%; color: #00b050;">&nbsp;&nbsp;&nbsp;&nbsp; </span><span style="font-size: 10pt; line-height: 107%;">This ECG was obtained from a 28-year-old woman who was found in her home, unresponsive.&nbsp; She was hypotensive at 99/35.&nbsp; No one was available to provide information about past medical history or the onset of this event.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">Before you read my comments, pause to look at the ECG and see what YOU think.<span style="mso-spacerun: yes;">&nbsp; </span>We would welcome comments below from all our members!</span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">The ECG</span></strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><span style="font-size: 10.0pt; line-height: 107%;">This ECG is quite challenging, as it illustrates the helpfulness of ECG changes in patient diagnosis, and also points out how important clinical correlation is when the ECG suggests multiple different problems. Forgive me in advance, but there is a lot to say about this ECG.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">The <strong style="mso-bidi-font-weight: normal;">heart rate</strong> is 148 bpm, and the <strong style="mso-bidi-font-weight: normal;">rhythm is regular</strong>, although not perfectly. <strong style="mso-bidi-font-weight: normal;">P waves</strong> are not seen, even though the ECG machine gives a P wave axis and PR interval measurement. The rate is fast enough to bury the P waves in the preceding T waves, especially if there is first-degree AV block. <strong style="mso-bidi-font-weight: normal;"><em style="mso-bidi-font-style: normal;"><span style="color: #7030a0;">Differential dx</span></em></strong><em style="mso-bidi-font-style: normal;"><span style="color: #7030a0;">:</span></em><span style="color: #7030a0;"> sinus tachycardia, PSVT, atrial flutter. </span>The very slight irregularity points more towards sinus tachycardia.<span style="mso-spacerun: yes;">&nbsp; </span>The rate of nearly 150 suggests atrial flutter with 2:1 conduction, but the only lead that looks remotely like it has flutter waves is V2. The lack of an onset or offset of the rhythm makes it difficult to diagnose PSVT with any certainty. </span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">The ECG machine measures the QRS complex at .102 seconds (102 ms). I don’t believe this is correct, as the QRS has an additional wave due to <strong style="mso-bidi-font-weight: normal;"><a href="https://www.ecgguru.com/ecg/instructors-collection-ecg-week-september-23-2015-right-bundle-branch-block-0">right bundle branch block pattern</a></strong>, and the machine did not count this terminal wave.<span style="mso-spacerun: yes;">&nbsp; </span>I measure the actual <strong style="mso-bidi-font-weight: normal;">QRS duration</strong> at closer to .12 seconds (120 ms).<span style="mso-spacerun: yes;">&nbsp; </span>The J point, or end point of the QRS complex, is difficult to see in most of the leads because of slurring from the QRS to the ST segment.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><em style="mso-bidi-font-style: normal;"><span style="font-size: 10.0pt; line-height: 107%; color: #7030a0;">Differential dx:</span></em></strong><span style="font-size: 10.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>There are some signs of <strong style="mso-bidi-font-weight: normal;"><a href="https://litfl.com/ecg-changes-in-pulmonary-embolism/">right ventricular failure</a></strong> on this ECG, but ECG is not 100% accurate for determining right heart strain. The ECG evidence must be confirmed by clinical correlation. <span style="mso-spacerun: yes;">&nbsp;</span>In a young person with sudden onset of right heart failure signs, one must consider <strong style="mso-bidi-font-weight: normal;">pulmonary embolus</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>Some, but not all, of the ECG signs that can be associated with pulmonary embolism are:</span></p><p class="MsoListParagraphCxSpFirst" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Sinus tachycardia (44%)</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right bundle branch block or incomplete RBBB (18%)</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right ventricular strain: T wave inversion in right precordial leads and inferior leads (only present here in V1 and Lead III, which is often normal).</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right axis deviation (16%).<span style="mso-spacerun: yes;">&nbsp; </span>Present here, but not severe at around 100 degrees.</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">S1 – Q3 – T3 the “classic” but not often present, sign of pulmonary embolism.<span style="mso-spacerun: yes;">&nbsp; </span>The<span style="mso-spacerun: yes;">&nbsp; </span>S wave in I may simply be the RBBB and the Q wave with T wave inversion may be a normal variant.</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Non-specific ST segment and T wave changes (50%)</span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">P pulmonale (we cannot see P waves)</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">There are also ST and T wave changes that resemble <strong style="mso-bidi-font-weight: normal;"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6282764/">Brugada Syndrome</a>, </strong>a genetic disorder of the sodium channel that can cause sudden death.<span style="mso-spacerun: yes;">&nbsp; </span>Illness can unmask the ECG changes that point to Brugada syndrome, but also there are conditions that cause similar ECG changes without the patient actually having a channelopathy. The shape of the ST and inverted T wave in V1 here are “Brugada like”. In Brugada Syndrome, those changes are usually seen in V1 and V2.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">The loss of P waves and the tall, peaked T waves with narrow bases are indicative of <strong style="mso-bidi-font-weight: normal;"><a href="https://rebelem.com/ecg-changes-hyperkalemia/">hyperkalemia</a></strong>. It is difficult to determine just from the ECG how far along the patient is in serum potassium levels, but widening of the QRS with loss of voltage is a dire sign.<span style="mso-spacerun: yes;">&nbsp; </span>Because hyperkalemia can progress swiftly to a “sine wave” pattern, it is crucial to make the diagnosis and begin treatment as soon as possible.<span style="mso-spacerun: yes;">&nbsp; </span>Usually, the serum K is high because the K has moved out of the intracellular space and entered the serum. Rather than remove K from the body, it is necessary to “push” it back into the cells, where it rightly belongs.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal" style="margin-bottom: .0001pt;"><span style="font-size: 10.0pt; line-height: 107%;">And, to make matters even more confusing, this ECG show signs of drug toxicity, specifically <strong style="mso-bidi-font-weight: normal;"><a href="https://litfl.com/tricyclic-overdose-sodium-channel-blocker-toxicity/">sodium channel blocker overdose</a>.<span style="mso-spacerun: yes;">&nbsp; </span></strong>Tricyclic antidepressants and some antiarrhythmics fall into this broad category. <span style="mso-spacerun: yes;">&nbsp;</span>Remember, this patient was found unresponsive, and we have no remote OR recent medical history.<span style="mso-spacerun: yes;">&nbsp; </span>Everything is on the table.<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span><span style="mso-spacerun: yes;">&nbsp;</span>ECG signs of sodium channel blocker OD include:</span></p><p class="MsoListParagraphCxSpFirst" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Sinus tachycardia</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Wide QRS complex</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Prolongation of the PR interval or QT interval</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right bundle branch block</span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; 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;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Brugada pattern</span></p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 10.0pt; color: #00b050;">Hospital Follow Up<span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span></strong><span style="font-size: 10.0pt;">At this time, we have only a preliminary follow up report.<span style="mso-spacerun: yes;">&nbsp; </span>Notably, this young woman was found to be in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298445/">diabetic ketoacidosis</a>, with a blood glucose level of 1,332 mg/dL! As a result, she was also hyperkalemic, with a serum potassium of 8.2.<span style="mso-spacerun: yes;">&nbsp; </span>The severe dehydration and acidosis of DKA cause sinus tachycardia.</span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><em style="mso-bidi-font-style: normal;"><span style="font-size: 10.0pt; line-height: 107%; color: #595959; mso-themecolor: text1; mso-themetint: 166; mso-style-textfill-fill-color: #595959; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: 'lumm=65000 lumo=35000';">Thanks to Sebastian Garay for donating this interesting ECG.</span></em></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/343/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 Tachycardia In An Unresponsive Patient 1/5</option><option value="40">Give Tachycardia In An Unresponsive Patient 2/5</option><option value="60">Give Tachycardia In An Unresponsive Patient 3/5</option><option value="80" selected="selected">Give Tachycardia In An Unresponsive Patient 4/5</option><option value="100">Give Tachycardia In An Unresponsive Patient 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.6</span></span> <span class="total-votes">(<span >16</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-SKj869PK4eEA5bz60FDHNkIrt5M7xLuk-CJzGrh8t70" /> <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/tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Tachycardia</a></div><div class="field-item odd"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><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/bifascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bifascicular block</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/right-axis-deviation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right axis deviation</a></div><div class="field-item even"><a href="/ecg/sa-exit-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">SA exit block</a></div><div class="field-item odd"><a href="/ecg/wide-qrs-complex" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide QRS complex</a></div><div class="field-item even"><a href="/ecg/diabetic-ketoacidosis" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Diabetic ketoacidosis</a></div><div class="field-item odd"><a href="/ecg/hyperkalemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperkalemia</a></div><div class="field-item even"><a href="/ecg/brugada-sign" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Brugada sign</a></div><div class="field-item odd"><a href="/ecg/tricyclic-antidepressant-overdose" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Tricyclic antidepressant overdose</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%2Ftachycardia-unresponsive-patient&amp;title=Tachycardia%20In%20An%20Unresponsive%20Patient"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 21 Aug 2019 02:48:51 +0000 Dawn 775 at https://www.ecgguru.com https://www.ecgguru.com/ecg/tachycardia-unresponsive-patient#comments Bifascicular Block With First-degree AVB https://www.ecgguru.com/ecg/bifascicular-block-first-degree-avb <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/bifascicular-block-first-degree-avb"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Bifascicular%20block%20w%20first%20degree%20AVB%20Dr%20Latifi.jpg" width="1800" height="953" 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"><div style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;"><strong style="color: #000000; font-family: 'Lucida Grande', 'Lucida Sans Unicode', sans-serif; font-size: 13.008px;"><span style="color: #00b050;">The Patient</span></strong><span style="font-family: 'Lucida Grande', 'Lucida Sans Unicode', sans-serif; font-size: 13.008px; color: #00b050;">&nbsp; </span><span style="color: #000000; font-family: 'Lucida Grande', 'Lucida Sans Unicode', sans-serif; font-size: 13.008px;">This ECG was obtained from an 80-year-old man with a past medical history of hypertension, diabetes, chronic obstructive pulmonary disease, hyperlipidemia, chronic kidney disease, and heart failure with preserved ejection fraction (HFpEF).</span></div><p class="MsoNormal">&nbsp;</p><p class="MsoNormal">He presented to the hospital with a complaint of shortness of breath, and was determined to have an exacerbation of his COPD in the setting of a viral infection.&nbsp; He was treated with breathing treatments and steroids, and was discharged home in improved condition.</p><p class="MsoNormal"><strong><span style="color: #00b050;">The ECG&nbsp;&nbsp; </span></strong>There is a sinus rhythm at 80 bpm.&nbsp; The QRS complex is wide at .18 seconds (180 ms). The PR interval is slightly prolonged at .24 seconds (240 ms), which is <strong>first-degree AV block</strong>. There is <strong>right bundle branch block</strong> (QR in V1 and rS in Leads I and V6 with a wide QRS).&nbsp; There is also a <strong>left posterior fascicular block</strong> (also called hemiblock), recognized by the right axis deviation (III is taller than aVF ).&nbsp; This is <strong>bi-fascicular block</strong>, which can be chronic or acute.&nbsp; There is very slight ST elevation with flattening in V1 and possibly V2.&nbsp; In RBBB, “normal” T waves are directed opposite the terminal wave of the QRS.&nbsp; V3 should, then, have inverted T waves. So, the upright T wave in this patient could be considered to be equivalent to an inversion in a normal ECG.&nbsp; V4 through V6 have biphasic T waves, which is not normal for RBBB.&nbsp; Because we do not have an old ECG, we don’t know which, if any, of these changes are chronic.&nbsp; With this patient’s past medical history, it is possible for any of them to be pre-existing.</p><p class="MsoNormal">I will admit that, when I first saw this ECG, the V1 rhythm strip at the bottom looked as though there were regular P waves at a rate of about 220-240, with one buried in each QRS and one in each T wave. In scrutinizing all the other leads, I cannot find evidence for an underlying atrial tachycardia or atrial flutter, so it is probably a coincidence that the P and T “march out” with the assumption of a hidden P wave in the QRS.</p><p class="MsoNormal"><strong><span style="color: #00b050;">The Conduction Blocks&nbsp;&nbsp; </span></strong>AV conduction blocks (AVB) can occur in any part of the conduction system from the AV node through the fascicles of the bundle branches. The ECG can offer valuable insights into what type of block is present, and even the location of the block, but often an EP study is needed to actually pinpoint the conduction defect.</p><p class="MsoNormal">&nbsp;AV blocks can cause slowing or failure of conduction.&nbsp; They can be chronic, permanent, temporary, intermittent, or even rate-related.&nbsp; A block of one of the left fascicles is called a “hemiblock” or “fascicular block”.&nbsp; A “bifascicular block” is a block of two of the three fascicles.&nbsp; A left bundle branch block is a bifascicular block, because the left bundle has two main fascicles.&nbsp; A common bifascicular block is right BBB with left anterior hemiblock, because those two fascicles share a blood supply.&nbsp; There are</p><p class="MsoNormal">This patient has a more unusual bifascicular block:&nbsp; right bundle branch block and &nbsp;left posterior hemiblock.&nbsp; He also has first-degree AVB.&nbsp; It has become customary to call this combination “tri-fascicular block”, but this is a misnomer.&nbsp; One would have to assume that the first-degree block is in the anterior fascicle for this to be “tri-fascicular”.&nbsp; If the conduction delay is actually in the AV node, this is still have a bi-fascicular block.&nbsp; One example of true tri-fascicular block would be second-degree AVB, Type II, which is a bi-fascicular block with an intermittent block in the third fascicle (intermittent tri-fascicular block).&nbsp; Another example of tri-fascicular block is complete heart block (third-degree) as a result of blocks in all three fascicles.&nbsp; Third-degree AVB caused by fascicular blocks would result in a ventricular escape rhythm, as opposed to an AV node complete block, which might have a junctional escape rhythm.&nbsp; An EP study, with H-V intervals measured, would be necessary to be sure of the levels of the blocks.&nbsp; The important thing here is that this patient has very significant chronic illness, is elderly, and has demonstrated bi-fascicular and possibly tri-fascicular disease.&nbsp; His likelihood of progressing to complete heart block is significant.&nbsp; Should he develop a complete tri-fascicular block, he would require a pacemaker.&nbsp; Remember, atropine will not work on infra-Hisian blocks (fascicular blocks). Another important clinical pearl is that any fascicular block which develops during an acute M.I. is much more likely to progress.&nbsp;</p><p class="MsoNormal">Fortunately, this patient’s ECG remained stable, and his condition improved with treatment, and he was able to be discharged home.</p><p class="MsoNormal">&nbsp;</p><p class="MsoNormal"><strong><span style="font-size: 10.0pt; line-height: 107%;">We would like to thank Dr. Ahmad Nawid Latifi, MD for providing this ECG.&nbsp;</span></strong></p><div style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;">&nbsp;</div><div style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;">&nbsp;</div><p><a href="https://www.healio.com/cardiology/learn-the-heart/ecg-review/ecg-topic-reviews-and-criteria/trifascicular-block-review">https://www.healio.com/cardiology/learn-the-heart/ecg-review/ecg-topic-reviews-and-criteria/trifascicular-block-review</a></p><p><a href="https://www.ajconline.org/article/0002-9149(74)90024-1/fulltext">https://www.ajconline.org/article/0002-9149(74)90024-1/fulltext</a></p><p><a style="font-size: 13.008px;" href="http://hqmeded-ecg.blogspot.com/2016/07/">http://hqmeded-ecg.blogspot.com/2016/07/</a></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/343/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 Bifascicular Block With First-degree AVB 1/5</option><option value="40">Give Bifascicular Block With First-degree AVB 2/5</option><option value="60">Give Bifascicular Block With First-degree AVB 3/5</option><option value="80" selected="selected">Give Bifascicular Block With First-degree AVB 4/5</option><option value="100">Give Bifascicular Block With First-degree AVB 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.6</span></span> <span class="total-votes">(<span >14</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-HLif7p0x1QyeH8hU-wIIo6CqDIb8jbKztCRl7ol3cAk" /> <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/bifascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bifascicular block</a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item even"><a href="/ecg/tri-fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Tri-fascicular block</a></div><div class="field-item odd"><a href="/ecg/left-posterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior hemiblock</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%2Fbifascicular-block-first-degree-avb&amp;title=Bifascicular%20Block%20With%20First-degree%20AVB%20"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 25 Apr 2019 03:29:37 +0000 Dawn 767 at https://www.ecgguru.com https://www.ecgguru.com/ecg/bifascicular-block-first-degree-avb#comments Jason's Blog: ECG Challenge for the month of June, 2013. https://www.ecgguru.com/blog/jasons-blog-ecg-challenge-month-june-2013 <div class="field field-name-field-blog-image field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/blog/jasons-blog-ecg-challenge-month-june-2013"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/ECG%20of%20the%20Month%202o%20ladder%20diagram.png" width="765" height="515" alt="" /></a></div></div></div><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>Unfortunately, I have no available clinical data on this patient.&nbsp; Merely looking for an interpretation of the ECG in it's raw form.</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/343/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 Jason&amp;#039;s Blog: ECG 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value="fivestar_custom_widget" /> </div></form></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%2Fblog%2Fjasons-blog-ecg-challenge-month-june-2013&amp;title=Jason%27s%20Blog%3A%20ECG%20Challenge%20for%20the%20month%20of%20June%2C%202013."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Mon, 27 May 2013 17:40:26 +0000 jer5150 452 at https://www.ecgguru.com https://www.ecgguru.com/blog/jasons-blog-ecg-challenge-month-june-2013#comments