ECG Guru - Instructor Resources - Sinus block https://www.ecgguru.com/ecg/sinus-block en An Irregular Bradycardia https://www.ecgguru.com/ecg/irregular-bradycardia <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/irregular-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20Lead%209%2029%20am.jpg" width="1800" height="1078" alt="" /></a></div><div class="field-item odd"><a href="/ecg/irregular-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12-Lead%2010%2042%20am.jpg" width="2008" height="1166" 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">Thank you to Alikuni Kllany from Toronto for donating these ECGs.&nbsp; They are from a 59-year-old man who has a history of hypertension and depression.&nbsp; Last year, he was on atenolol when he experienced a brief syncopal episode and bradycardia. He was taken off atenolol and started on amlodipine 5 mg.&nbsp; He also takes ramipril 10 mg, atorvastatin 40 mg, and tamsulosin .4 mg.&nbsp; He continues to have bradycardia and dizziness.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The first ECG shows grouped beating, with repetitive groups of two and three complexes.&nbsp; The P waves are very small, and hard to evaluate.&nbsp; The best place to see them is in the Lead II rhythm strip at the bottom.&nbsp; The rhythm strip is not run concurrently with the 12-Lead, making it even more difficult to evaluate P wave morphology.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The beats that begin the groups also END a pause.&nbsp; These are junctional escape beats.&nbsp; After the junctional escape beats, the PR intervals vary.&nbsp; This can be explained by <a href="http://ecgguru.com/expert-review/ask-expert-6">RP / PR reciprocity</a>, first described by Mobitz.&nbsp; He demonstrated that the RP interval can affect the next PR interval. Longer RP intervals (slower rate) cause PR shortening.&nbsp; Shorter RP intervals equal longer PR intervals.&nbsp; The P waves are so small, it is difficult to determine whether there is a P wave in the last T wave of each group, which would indicate non-conducted PACs.&nbsp; So, we are left with a sinus pause or sinus exit block (suggested by the timing of the first six beats.&nbsp; We have used red arrows to suggest where the sinus node probably fired.&nbsp; P waves indicate conduction, of course.&nbsp; Lack of P waves, the impulse failed to exit the sinus node.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">There are many mechanisms by which grouped beating can occur.&nbsp; Second-degree AVB, Type I (Wenckebach) comes to mind first.&nbsp; That rhythm in it’s pure form would have a regular sinus rhythm underlying it. &nbsp;&nbsp;Escape-capture bigeminy often occurs with slow rates and junctional escapes, but does not by itself cause “trigeminy”.&nbsp; Sick sinus syndrome can cause all types of chaos in the rhythm.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The second tracing shows a junctional escape rhythm with no obvious P waves (unsure because the P waves are small, and the 12-Lead is not concurrent with the rhythm strip at the bottom.)&nbsp; It is interesting that the rhythm strip shows four consecutive sinus beats at just under 60 bpm, and with P waves that look different from the P waves on the first ECG. &nbsp;This rate is similar, but not identical to, the sinus rate seen in the first ECG.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The bottom line for the clinician is that this patient, because he is symptomatic, requires a thorough workup.&nbsp; If the cause of the arrhythmias proves to be cardiac in origin, a pacemaker may be required.</p><p class="MsoNormal"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></p><p>&nbsp;</p><p class="MsoNormal">We welcome any and all discussions regarding this ECG, realizing that P waves are very difficult to evaluate, and that they are probably multi-focal.</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/415/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 An Irregular Bradycardia 1/5</option><option value="40">Give An Irregular Bradycardia 2/5</option><option value="60">Give An Irregular Bradycardia 3/5</option><option value="80">Give An Irregular Bradycardia 4/5</option><option value="100" selected="selected">Give An Irregular Bradycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.3</span></span> <span class="total-votes">(<span >7</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-dTXnszNpXvvykeq-tWpgnjHmStBnzdbeSSch8X7Dwv8" /> <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/junctional-escape" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional escape</a></div><div class="field-item odd"><a href="/ecg/escape-capture-bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Escape-capture bigeminy</a></div><div class="field-item even"><a href="/ecg/r-p-p-r-reciprocity" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">R-P / P-R reciprocity</a></div><div class="field-item odd"><a href="/ecg/sinus-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus block</a></div><div class="field-item even"><a href="/ecg/sinus-pause" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus pause</a></div><div class="field-item odd"><a href="/ecg/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</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%2Firregular-bradycardia&amp;title=%20%20An%20Irregular%20Bradycardia"><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> Thu, 31 Mar 2016 21:05:12 +0000 Dawn 693 at https://www.ecgguru.com https://www.ecgguru.com/ecg/irregular-bradycardia#comments ECG Basics: Sinus Pause / Sinus Arrest https://www.ecgguru.com/ecg/ecg-basics-sinus-pause-sinus-arrest <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-pause-sinus-arrest"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/123%20Sinus%20arrest.jpg" width="1800" height="357" 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 example of sinus arrest, also called sinus pause, shows a spontaneous return to sinus rhythm. &nbsp;There are many mechanisms by which pauses can occur on the ECG. One concept for beginner students to grasp is that, if the pause contains the equivalent of regular R-to-R intervals, and the first complex after the pause is "on time", &nbsp;we can expect that the sinus node kept firing, but did not penetrate the atria (exit block). If the pause is irregular in length, with the first beat after the pause seeming to come in randomly, we can call this sinus arrest or pause, understanding that there are many different mechanisms that can be at work here. Because what little we can see of the underlying sinus rhythm is irregular, or speeding up, we cannot discern absolutely that this is sinus arrest.&nbsp;</p><p>The bottom line for the patient, and for any level practitioner, is, "how is the patient tolerating this pause, and what does it mean to the patient's overall prognosis? &nbsp;In the short term, the patient may require emergency pacing while the cause of the dysfunction is investigated. If pauses are long enough to lower cardiac output, they can cause fainting. More than a few automobile accidents have happened as a result of this type of dysrhythmia.&nbsp;</p><p>For more advanced students, this short rhythm strip (Lead II) reveals sloping ST depression, and indicates the urgent need for a 12-lead ECG and other tests.&nbsp;</p><p>&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/415/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 ECG Basics: Sinus Pause / Sinus Arrest 1/5</option><option value="40">Give ECG Basics: Sinus Pause / Sinus Arrest 2/5</option><option value="60">Give ECG Basics: Sinus Pause / Sinus Arrest 3/5</option><option value="80">Give ECG Basics: Sinus Pause / Sinus Arrest 4/5</option><option value="100" selected="selected">Give ECG Basics: Sinus Pause / Sinus Arrest 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.1</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--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-oAdmeGZS93Bw-D-0EAOQfZlgpNFliPnM5oPPK9c0h5Y" /> <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-arrest" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus arrest</a></div><div class="field-item even"><a href="/ecg/sinus-pause" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus pause</a></div><div class="field-item odd"><a href="/ecg/st-depression" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST depression</a></div><div class="field-item even"><a href="/ecg/sinus-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus 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_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fecg-basics-sinus-pause-sinus-arrest&amp;title=ECG%20Basics%3A%20%20Sinus%20Pause%20%2F%20Sinus%20Arrest%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, 12 Dec 2013 17:03:41 +0000 Dawn 525 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-sinus-pause-sinus-arrest#comments