ECG Guru - Instructor Resources - Teaching series https://www.ecgguru.com/ecg/teaching-series en Teaching Series - Tachycardia and Left Anterior Fascicular Block https://www.ecgguru.com/ecg/teaching-series-tachycardia-and-left-anterior-fascicular-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/teaching-series-tachycardia-and-left-anterior-fascicular-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LAH101%20A.jpg" width="1800" height="666" alt="" /></a></div><div class="field-item odd"><a href="/ecg/teaching-series-tachycardia-and-left-anterior-fascicular-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LAH101%20%20-%20B_0.jpg" width="1600" height="1175" alt="" /></a></div><div class="field-item even"><a href="/ecg/teaching-series-tachycardia-and-left-anterior-fascicular-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LAH101%20%20C.jpg" width="1707" height="1309" 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"><span style="font-size: 12.0pt; line-height: 107%;">This series of three ECGs is from a 60-year-old man who was brought to the Emergency Department after being involved in a motor vehicle accident.&nbsp; No injuries were found, but the patient was severely intoxicated by alcohol consumption.&nbsp; He was conscious but agitated.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">ECG NO. 1&nbsp;&nbsp; &nbsp;&nbsp;15:07:23</span></strong></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The first ECG was taken by fire-rescue personnel at the scene of the accident. His hemodynamic status was stable, and the rate was not addressed in the field. ECG No. 1 shows a supraventricular rhythm at 161 bpm, with a narrow QRS and P waves visible before each QRS.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">A notable feature of this ECG are the left axis deviation, by default diagnosed at left anterior hemiblock (left anterior fascicular block).&nbsp; The .10 second QRS width is typical of LAHB, as is the rS pattern in Lead III.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Also &nbsp;noted is the unusual R wave progression in the precordial leads.&nbsp; The R waves are prominent in V2, and then fail to progress across the precordium, and the S waves persist.&nbsp;</span><span style="font-size: 12pt;">This is probably due to the hemiblock.</span><span style="font-size: 12pt;">&nbsp; </span><span style="font-size: 12pt;">We do not know this patient’s medical history, except that he self-described as an “alcoholic”.</span><span style="font-size: 12pt;">&nbsp; </span><span style="font-size: 12pt;">LAFB can be associated with coronary artery disease.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">ECG NO. 2&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;15:20:38</span></strong></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Now being evaluated in the Emergency Dept., we see the patient's heart rate is 163 bpm.&nbsp; Some variability in the rate was noted with patient agitation and activity, so it was determined that the rhythm was probably sinus tachycardia.&nbsp; There were no other significant changes in the ECG from the first one.&nbsp; Unfortunately, we no longer have access to lab results, so we do not know his electrolyte or hydration status.&nbsp; Labs confirmed ETOH intoxication.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">ECG NO. 3&nbsp; &nbsp;15:43:26</span></strong></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">After IV fluids and a short rest, the patient is much less agitated, and is conversant.&nbsp; His heart rate is now 105 bpm.&nbsp; This rate was reached by gradual increments, further evidence that this was SINUS TACHYCARDIA all along.&nbsp; Reentrant rhythms (AVNT, AVNRT, atrial flutter) start and stop abruptly.&nbsp; Some leads on ECG No. 3 may suggest an underlying atrial flutter (aVR, aVF), but the waves do not “march out”.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">SINUS TACHYCARDIA VS. PSVT</span></strong></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">At rates over 140 per minute, it can sometimes be difficult to differentiate sinus tach from reentrant tachycardias (PSVT).&nbsp; Seeing gradual adjustments of the rate favors a diagnosis of sinus tach.&nbsp; Also, seeing an obvious “cause” of sinus tach helps.&nbsp; In this case, the patient was a chronic alcohol abuser who was intoxicated.&nbsp; This is associated with sinus tachycardia, due to stimulation of catecholamine secretion and cell membrane alterations.&nbsp; Also, he was agitated and possibly dehydrated.</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/436/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 Teaching Series - Tachycardia and Left Anterior Fascicular Block 1/5</option><option value="40">Give Teaching Series - Tachycardia and Left Anterior Fascicular Block 2/5</option><option value="60">Give Teaching Series - Tachycardia and Left Anterior Fascicular Block 3/5</option><option value="80" selected="selected">Give Teaching Series - Tachycardia and Left Anterior Fascicular Block 4/5</option><option value="100">Give Teaching Series - Tachycardia and Left Anterior Fascicular Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.1</span></span> <span class="total-votes">(<span >11</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-BXhuyqcktMXI_bOqwtPEiOHh3LTBA1XEF0og-eUvhWI" /> <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/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><div class="field-item odd"><a href="/ecg/supraventricular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Supraventricular tachycardia</a></div><div class="field-item even"><a href="/ecg/psvt" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PSVT</a></div><div class="field-item odd"><a href="/ecg/teaching-series" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Teaching series</a></div><div class="field-item even"><a href="/ecg/left-anterior-fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior fascicular block</a></div><div class="field-item odd"><a href="/ecg/left-anterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior hemiblock</a></div><div class="field-item even"><a href="/ecg/poor-r-wave-progression-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Poor R wave progression</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%2Fteaching-series-tachycardia-and-left-anterior-fascicular-block&amp;title=Teaching%20Series%20-%20Tachycardia%20and%20Left%20Anterior%20Fascicular%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> Sat, 15 Oct 2016 21:48:02 +0000 Dawn 712 at https://www.ecgguru.com https://www.ecgguru.com/ecg/teaching-series-tachycardia-and-left-anterior-fascicular-block#comments Atrial Fib To Cardiac Arrest https://www.ecgguru.com/ecg/atrial-fib-cardiac-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/atrial-fib-cardiac-arrest"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AF%20Pre%20Torsades%2012%20Lead.jpg" width="1800" height="741" alt="" /></a></div><div class="field-item odd"><a href="/ecg/atrial-fib-cardiac-arrest"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Rhythm%20strips%20cropped%20for%20Guru.jpg" width="1800" height="1018" 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"><span style="font-size: 10pt; line-height: 107%; font-family: 'Calibri Light', sans-serif; color: #222222; background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;">A paramedic crew responded to the office of a local physician. A 61-year-old male presented with a one-week history of chest pain and shortness of breath. He had a previously undiagnosed atrial fibrillation with rapid ventricular response and left bundle branch block, but was alert. Shortly after transport commenced, the patient became unresponsive with Torsades de Pointes, which rapidly degenerated into ventricular fibrillation. The paramedic placed pads and defibrillated<span class="apple-converted-space">&nbsp;within one minute. &nbsp;After two minutes of compressions, the patient had a fairly regular rhythm with return of spontaneous circulation. &nbsp;Transport time was short. &nbsp;On catheterization, the patient was found to have severe coronary artery disease, requiring coronary artery bypass graft surgery (CABG) A balloon pump was inserted in an attempt to strengthen him for surgery.</span></span></p> <p class="MsoNormal"><strong><span style="font-size: 10pt; line-height: 107%; font-family: 'Calibri Light', sans-serif; color: #222222; background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;">What is the rhythm? &nbsp;&nbsp;</span></strong><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">The 12-lead ECG presented here shows atrial fibrillation at a rate of 138 per minute.</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">The rhythm is irregularly-irregular with no P waves.</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">Since the patient had not yet been diagnosed with atrial fib, obviously no therapy had been initiated to control the rate. There is a PVC near the end of the strip.</span></p> <p class="MsoNormal"><strong><span style="font-size: 10pt; line-height: 107%; font-family: 'Calibri Light', sans-serif; color: #222222; background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;">Why is the QRS complex wide? &nbsp;</span></strong><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">The QRS complex is wide at 0.168 sec (168 ms).</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">It meets the ECG criteria for<a title="LBBB Criteria" href="http://ecgguru.com/ecg/left-bundle-branch-block-0"> left bundle branch block</a> (wide QRS, supraventricular rhythm, negative V</span><sub style="color: #222222; font-family: 'Calibri Light', sans-serif; line-height: 107%;">1</sub><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;"> and positive Leads I and V</span><sub style="color: #222222; font-family: 'Calibri Light', sans-serif; line-height: 107%;">6</sub><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">). Atrial fibrillation can lower cardiac output because there is no P wave, and therefore, no “atrial kick”. Left BBB can lower cardiac output because a wide QRS is a sign of unsynchronized depolarization of the ventricular muscle, which causes less pumping force. To help you determine if a rhythm is LBBB or VT, review <a title="Brugada Criterion" href="http://ecgguru.com/ecg/brugada-criterion">Brugada's Criterion</a>.</span></p> <p class="MsoNormal"><strong><span style="font-size: 10pt; line-height: 107%; font-family: 'Calibri Light', sans-serif; color: #222222; background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;">Are there ST changes? &nbsp;</span></strong><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">In <a title="Sgarbossa" href="http://ecgguru.com/ecg/sgarbossa-criteria">wide-complex rhythms</a>, it can be difficult to determine whether acute M.I. is present, because the wide QRS is normally accompanied by “discordant ST changes”.</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">That is, if the QRS is positive, the ST and T wave are negative. If the QRS is negative, the ST and T will be elevated.</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">In this ECG, there is a subtle ST elevation in Leads III and aVR, and subtle ST depression in I and aVL.</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">It is difficult to attribute this to A.M.I., but subsequent events point to that as the diagnosis.</span></p> <p class="MsoNormal"><strong><span style="font-size: 10pt; line-height: 107%; font-family: 'Calibri Light', sans-serif; color: #222222; background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;">What about the rhythm strips that follow? &nbsp;&nbsp;</span></strong><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">The rhythm strips provided show the patient’s quick progression, during transport to the hospital, from atrial fib with PVCs to <a title="Torsades" href="http://ecgguru.com/ecg/torsades-de-pointes">Torsades de Pointes</a>, to V Fib.</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">They show an electrical shock at 200 joules approximately 1 minute after the VT started.</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">This shock successfully converted the patient’s rhythm.</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">First, it appears that the rhythm may be atrial flutter with 4:1 conduction (or it may be baseline artifact).</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">By the final strip shown, we see a regular rhythm without clear P waves at a rate of 50 bpm.</span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">&nbsp; </span><span style="color: #222222; font-family: 'Calibri Light', sans-serif; font-size: 10pt; line-height: 107%;">This could be a junctional rhythm, difficult to assess with only a 2-lead rhythm strip.</span><span style="color: #222222; font-family: Arial, sans-serif; font-size: 10pt; line-height: 107%;">&nbsp;</span></p> <h3 class="MsoNormal"><span style="font-size: 10pt; line-height: 107%; color: #222222; background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;"><strong>This series provides many teaching opportunities.</strong>&nbsp; </span></h3> <p class="MsoNormal"><span style="font-size: 10pt; line-height: 107%; color: #222222; background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;">1) Both atrial fib with LBBB and VT can cause a WIDE-COMPLEX TACHYCARDIA. </span></p> <p class="MsoNormal"><span style="font-size: 10pt; line-height: 107%; color: #222222; background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;">2) It can be difficult to see the classic signs of STEMI when BBB is present.</span></p> <p class="MsoNormal"><span style="font-size: 10pt; line-height: 107%; color: #222222; background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;">3) VT can progress VERY RAPIDLY to V Fib, especially in low-output conditions.</span></p> <p class="MsoNormal"><span style="font-size: 10pt; line-height: 107%; color: #222222; background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;">4) Effective chest compressions and quick defibrillation will often result in conversion to an organized rhythm.&nbsp; Defibrillating the perfused heart is infinitely more effective that shocking a poorly-perfused heart.<strong> Kudos to this crew for a job well done.</strong></span><span style="font-size: 10.0pt; line-height: 107%; mso-bidi-font-family: Arial; color: #222222;"><br> </p> <!--[if !supportLineBreakNewLine]--><p><br> </p> <!--[endif]--><p></span></p> <p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">&nbsp;</span></p> <p>&nbsp;</p> <p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">&nbsp;</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/436/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 Atrial Fib To Cardiac Arrest 1/5</option><option value="40">Give Atrial Fib To Cardiac Arrest 2/5</option><option value="60">Give Atrial Fib To Cardiac Arrest 3/5</option><option value="80" selected="selected">Give Atrial Fib To Cardiac Arrest 4/5</option><option value="100">Give Atrial Fib To Cardiac Arrest 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4</span></span> <span class="total-votes">(<span >10</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-2yCKMt8vc3dghLuHiD2UxI8JGgqyOrALUZ_4yEYo9v8" /> <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/teaching-series" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Teaching series</a></div><div class="field-item odd"><a href="/ecg/ivcd" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IVCD</a></div><div class="field-item even"><a href="/ecg/atrial-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial fibrillation</a></div><div class="field-item odd"><a href="/ecg/left-bundle-branch-block-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left bundle branch block</a></div><div class="field-item even"><a href="/ecg/torsades-de-pointes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Torsades de Pointes</a></div><div class="field-item odd"><a href="/ecg/v-fib-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">V Fib</a></div><div class="field-item even"><a href="/ecg/v-tach" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">V Tach</a></div><div class="field-item odd"><a href="/ecg/ventricular-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular fibrillation</a></div><div class="field-item even"><a href="/ecg/ventricular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular tachycardia</a></div><div class="field-item odd"><a href="/ecg/defibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Defibrillation</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/acute-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Acute 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_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fatrial-fib-cardiac-arrest&amp;title=Atrial%20Fib%20To%20Cardiac%20Arrest"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 03 Jul 2016 20:31:52 +0000 Dawn 705 at https://www.ecgguru.com https://www.ecgguru.com/ecg/atrial-fib-cardiac-arrest#comments Teaching Series: Acute Anterior Wall M.I. https://www.ecgguru.com/ecg/teaching-series-acute-anterior-wall-mi <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/teaching-series-acute-anterior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AMI%20for%20site.jpg" width="1800" height="2476" 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>Intermittent chest pain. &nbsp; &nbsp;&nbsp;</strong><span style="font-size: 13.008px; line-height: 1.538em;">This series of three ECG were taken from a 41-year-old man with a two-week history of intermittent chest pain.&nbsp; At the time of the first ECG, 12:05 pm, he was pain-free.&nbsp; We see a sinus tachycardia at 102 bpm, and has just come under the care of paramedics. There is a very subtle ST sagging and T wave inversion in Lead III, and no other ST changes. He had an uneventful trip to the hospital.</span></p><p class="MsoNormal"><span style="font-size: 13.008px; line-height: 1.538em;">On arrival at the Emergency Department, just before he was unloaded from the ambulance (12:15), he experienced chest pain.</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp; </span><span style="font-size: 13.008px; line-height: 1.538em;">An ECG was obtained, which shows ST elevation in V1 through V4, as well as in Leads I and avL.</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp; </span><span style="font-size: 13.008px; line-height: 1.538em;">There are reciprocal ST depressions in Leads III and aVF.</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal">The patient was taken into the ED, where his symptoms abated, and a third ECG was obtained (12:19). The third ECG looks very much like the first one. V5 and V6 have T waves that appear flat, or even inverted, but there is some baseline artifact making it hard to see them.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal"><strong>Diagnosis confirmed &nbsp; &nbsp; &nbsp;&nbsp;</strong>Based on the patient’s presentation, and the second ECG, he was taken immediately to the cath lab. A 100% occluding lesion with a clot was discovered in the mid LAD.&nbsp; The clot was removed with suction, and the lesion stented.&nbsp; A 40% narrowing was discovered in the RCA.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span>&nbsp;</p><p class="MsoNormal"><strong>Repeat ECGs whenever possible</strong> &nbsp; &nbsp; &nbsp; This series of ECGs offers a compelling argument for performing repeat ECGs.&nbsp; This can be especially important when symptoms are waxing and waning.&nbsp; Sometimes, a clot can completely occlude an artery, then “float” to another position, allowing blood flow to resume.&nbsp; Sometimes, the artery constricts around the lesion, causing occlusion, then relaxes.&nbsp; Had the rescue crew not repeated the ECG at 12:19, there may have been a delay in this young patient receiving interventional care.</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/436/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 Teaching Series: Acute Anterior Wall M.I. 1/5</option><option value="40">Give Teaching Series: Acute Anterior Wall M.I. 2/5</option><option value="60">Give Teaching Series: Acute Anterior Wall M.I. 3/5</option><option value="80">Give Teaching Series: Acute Anterior Wall M.I. 4/5</option><option value="100" selected="selected">Give Teaching Series: Acute Anterior Wall M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.8</span></span> <span class="total-votes">(<span >4</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-OaT95c5SHmHSB6VTJxSZaoIP2i9Uy_9lZDUMovPasYk" /> <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/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item odd"><a href="/ecg/teaching-series" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Teaching series</a></div><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/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</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%2Fteaching-series-acute-anterior-wall-mi&amp;title=Teaching%20Series%3A%20Acute%20Anterior%20Wall%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 26 Jun 2016 21:33:28 +0000 Dawn 704 at https://www.ecgguru.com https://www.ecgguru.com/ecg/teaching-series-acute-anterior-wall-mi#comments Teaching Series: Anterior Wall M.I. https://www.ecgguru.com/ecg/teaching-series-anterior-wall-mi <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/teaching-series-anterior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AW101A%2BOPP%204%2009%20am.jpg" width="1800" height="1397" alt="" /></a></div><div class="field-item odd"><a href="/ecg/teaching-series-anterior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AW101B%2BOPP%206%2029%20am.jpg" width="1800" height="1326" alt="" /></a></div><div class="field-item even"><a href="/ecg/teaching-series-anterior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AW101C%2BOPP%202%20days%20later_0.jpg" width="1800" height="1351" 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>A series of ECGs can be a valuable addition to any teacher's collection. &nbsp;This series follows a 75-year-old woman through three days, during which she experienced an acute anterior wall M.I., a catheterization with angioplasty and stents placement.</p><p>In the first ECG, taken at 4:09 am, the patient has presented to the Emergency Dept. with a complaint of chest pain. (Other details are no longer available). &nbsp;Although there is some baseline artifact, it appears that the rhythm is sinus rhythm with one PAC (7th beat). &nbsp;There is subtle but measurable ST elevation in V1, V2, and V3 (anterior-septal leads). &nbsp;The shape of the STE in V1 is noticeably coved upward. &nbsp;Even aVR has some STE, with coving. &nbsp;There is equally subtle ST depression in Leads II, III, and aVF (inferior leads). &nbsp;Fortunately, there are no pathological Q waves at this point,&nbsp;<span style="font-size: 12.7272720336914px; line-height: 1.538em;">which would be an indication of necrotic tissue in the area of the M.I. (anterior-septal wall).</span></p><p>The patient was taken to the cath lab, where it was found that she had a 100% mid-left anterior descending artery occlusion, which was opened and stented. &nbsp;She also was found to have widespread coronary artery disease, with the left circumflex artery 25% occluded (stented), the right coronary artery (which was dominant) proximately occluded 50% and stented, and the posterior descending artery 75% occluded (stented).</p><p>The second ECG, taken at 6:29 the same morning, after the cath procedure, shows some ST elevation with coving remaining in V1 through V3, and also aVR, but now with the loss of R waves in V1 and V2 and loss of R wave voltage in V3. &nbsp;This represents the formation of pathological Q waves, and can be a permanent change in many cases.</p><p>The third ECG, taken two days later in the cardiac step-down unit, shows improvement, and progression toward healing. &nbsp;The ST segments are still shaped in a slightly coved-upward shape, but they are less elevated. &nbsp;The R waves have returned. &nbsp;The T waves in V1-V3 are inverted. &nbsp;The deeply inverted T waves of V2 and V3, especially, and classic for ischemia, and we even see the "ischemic zone" extending across the anterior-lateral wall, including V4 through V6 and Leads I and aVL.</p><p>The patient did very well to discharge, and we don't have followup after that.</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/436/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 Teaching Series: Anterior Wall M.I. 1/5</option><option value="40">Give Teaching Series: Anterior Wall M.I. 2/5</option><option value="60">Give Teaching Series: Anterior Wall M.I. 3/5</option><option value="80" selected="selected">Give Teaching Series: Anterior Wall M.I. 4/5</option><option value="100">Give Teaching Series: Anterior Wall M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.8</span></span> <span class="total-votes">(<span >4</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-ODP7ZQXkl-I9Um5VfGC0loAVgGHRAqPLZcM4_FXypxc" /> <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/anterior-wall-mi-5" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior wall M.I.</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/teaching-series" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Teaching series</a></div><div class="field-item odd"><a href="/ecg/ecg-teaching-series" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG teaching series</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/myocardial-infarction" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Myocardial infarction</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%2Fteaching-series-anterior-wall-mi&amp;title=Teaching%20Series%3A%20%20Anterior%20Wall%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 28 Jan 2015 05:31:25 +0000 Dawn 616 at https://www.ecgguru.com https://www.ecgguru.com/ecg/teaching-series-anterior-wall-mi#comments ECG Basics: Paroxysmal Supraventricular Tachycardia Treated With Adenosine https://www.ecgguru.com/ecg/ecg-basics-paroxysmal-supraventricular-tachycardia-treated-adenosine <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-paroxysmal-supraventricular-tachycardia-treated-adenosine"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/136%20PSVT%20before%20Adenosine.jpg" width="1600" height="276" alt="" /></a></div><div class="field-item odd"><a href="/ecg/ecg-basics-paroxysmal-supraventricular-tachycardia-treated-adenosine"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/136%20PSVT%20after%20Adenosine.jpg" width="1791" height="269" alt="" /></a></div><div class="field-item even"><a href="/ecg/ecg-basics-paroxysmal-supraventricular-tachycardia-treated-adenosine"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/136%20after%20Adenosine%202.jpg" width="1800" height="254" 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="color: #00b050;">This series of ECG rhythm strips shows a paroxysmal supraventricular tachycardia successfully treated with adenosine</span></strong>.&nbsp; The patient was complaining of a rapid heart rate and palpitations, but was hemodynamically stable.&nbsp; It is not known whether any parasympathetic stimulation, such as a Valsalva maneuver or carotid sinus massage, was used initially. &nbsp;<strong style="font-size: 12.7272720336914px; line-height: 1.538em;"><span style="color: #00b050;">&nbsp;</span></strong></p><p class="MsoNormal"><strong><span style="color: #00b050;">The first rhythm strip&nbsp;</span></strong>shows a PSVT, presumably AV nodal reentrant tachycardia, at a rate of about 215 per minute. &nbsp;(We originally indicated a rate of 240 per minute, but this was a typo). Using the simplist method of determining rate, the six-second method, we see 21, but almost 22, QRS complexes in six seconds. Differential diagnosis would include sinus tachycardia, but this rate is too fast for sinus tach, especially in a resting patient.&nbsp; Also, sinus tach would slow down as the patient is rested or made more comfortable, and this rate did not vary.&nbsp; Also, when confronted with a supraventricular tachycardia, one should also consider atrial flutter and atrial fibrillation.&nbsp; This is somewhat slow for atrial flutter with 1:1 conduction, and that rhythm is much more rare than AVNRT. It is too regular for atrial fibrillation. &nbsp;So, we are left with the probable diagnosis of paroxysmal supraventricular tachycardia.&nbsp; The “paroxysmal” part is presumed since AVNRT has an abrupt onset, and the patient’s symptoms started suddenly.<span style="font-size: 12.7272720336914px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="color: #00b050;">The second rhythm strip&nbsp;</span></strong>shows what happened after adenosine was administered.&nbsp; The patient received first a 6 mg dose, rapid IV push.&nbsp; When that was not effective, he received 12 mg rapid IV push.&nbsp; The rhythm strip is typical of the first minute or so after adenosine administration.&nbsp; Adenosine can cause transient AV blocks, escape rhythms, and ectopic irritability.&nbsp; The half-life of adenosine is only 6 seconds, so the dysrhythmias and uncomfortable symptoms are short-lived.&nbsp; In this strip, we see frequent PVCs and runs of V tach.&nbsp;<span style="font-size: 12.7272720336914px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal">An interesting feature of this strip is <strong>FUSION BEATS.</strong>&nbsp; In ventricular rhythms, the wave of depolarization travels backwards (retrograde conduction).&nbsp; If the ventricular beat is timed just right, it might meet a sinus beat on its way down the conduction system.&nbsp; The two impulses will fuse and the QRS complex will look like a hybrid of the two.&nbsp; Beats 1 &amp; 2 show the PSVT, beats 3, 4, 5, and 6 show a run of V tach.&nbsp; Beat 7 has a sinus P wave, but the morphology closely resembles the PVCs.&nbsp; It is a fusion beat.&nbsp; Beat 8 is a fusion, and 9 and 10 are PVCs.&nbsp; Beat 11 is a sinus capture beat.&nbsp; The P wave is lost in the preceding T wave, but the morphology of the QRS matches the PSVT, indicating normal conduction through the ventricles.&nbsp; After two more PVCs, the patient has sinus beats and a PAC (Beat 20), then settles into sinus rhythm at a rate of about 100/min.<strong style="font-size: 12.7272720336914px; line-height: 1.538em;"><span style="color: #00b050;">&nbsp;Fusion beats prove the existence of a ventricular rhythm, as two sinus or atrial impulses cannot fuse. &nbsp;</span></strong></p><p class="MsoNormal"><strong><span style="color: #00b050;">The third strip&nbsp;</span></strong>shows normal sinus rhythm at a rate of about 95 / min with two PACs (arrows).&nbsp; The patient had had quite an exciting time in the emergency department, and his adrenalin caused a fast rate.&nbsp; It appropriately slowed down over the next 15 minutes.</p><p class="MsoNormal">&nbsp;</p><p>&nbsp;</p><p class="MsoNormal">&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/436/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 ECG Basics: Paroxysmal Supraventricular Tachycardia Treated With Adenosine 1/5</option><option value="40">Give ECG Basics: Paroxysmal Supraventricular Tachycardia Treated With Adenosine 2/5</option><option value="60">Give ECG Basics: Paroxysmal Supraventricular Tachycardia Treated With Adenosine 3/5</option><option value="80">Give ECG Basics: Paroxysmal Supraventricular Tachycardia Treated With Adenosine 4/5</option><option value="100" selected="selected">Give ECG Basics: Paroxysmal Supraventricular Tachycardia Treated With Adenosine 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.2</span></span> <span class="total-votes">(<span >9</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--5" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-t8BZIqiW4sc_fgzB-eCB0jHR5ky-5lXB3jvdNd2hS-k" /> <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/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item even"><a href="/ecg/basic-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Basic ECG</a></div><div class="field-item odd"><a href="/ecg/teaching-series" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Teaching series</a></div><div class="field-item even"><a href="/ecg/ecg-teaching-series" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG teaching series</a></div><div class="field-item odd"><a href="/ecg/paroxysmal-supraventricular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Paroxysmal supraventricular tachycardia</a></div><div class="field-item even"><a href="/ecg/avnrt" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AVNRT</a></div><div class="field-item odd"><a href="/ecg/v-tach" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">V Tach</a></div><div class="field-item even"><a href="/ecg/fusion-beats" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Fusion beats</a></div><div class="field-item odd"><a href="/ecg/adenosine" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Adenosine</a></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%2Fecg%2Fecg-basics-paroxysmal-supraventricular-tachycardia-treated-adenosine&amp;title=ECG%20Basics%3A%20%20Paroxysmal%20Supraventricular%20Tachycardia%20Treated%20With%20Adenosine"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 28 Dec 2014 23:43:18 +0000 Dawn 612 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-paroxysmal-supraventricular-tachycardia-treated-adenosine#comments Teaching Series: Atrial Fibrillation With Left Bundle Branch Block https://www.ecgguru.com/ecg/teaching-series-atrial-fibrillation-left-bundle-branch-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/teaching-series-atrial-fibrillation-left-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LBAF100A.jpg" width="1800" height="751" alt="" /></a></div><div class="field-item odd"><a href="/ecg/teaching-series-atrial-fibrillation-left-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LBAF100B.jpg" width="1800" height="691" 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 good example of atrial fibrillation with left bundle branch block. &nbsp;You get two ECGs with this one, because the patient presented to EMS with a fast heart rate, and the rate was slowed with the drug diltiazem. &nbsp;We do not have any other patient information, unfortunately.</p><p>In the first strip, we see a wide-complex tachycardia. &nbsp;In an emergency situation, with an unstable patient, this rhythm could safely be treated using an emergency ventricular tachycardia (VT) protocol. &nbsp;In fact, all WCTs should be considered to be VT until proven otherwise. &nbsp;In most emergency settings, the unstable VT patient would be electrically cardioverted, which will often convert atrial fibrillation as well. &nbsp;The stable patient with this rhythm would be treated with an antiarrhythmic drug, such as amiodarone. &nbsp;This may convert or slow down atrial fib. &nbsp;So, in the initial stages of treatment, differentiating between VT and A Fib is not the first priority. &nbsp;Assessing the patient's hemodynamic stability and addressing the rate if necessary are the priorities. &nbsp;</p><p>So, how do we know this is NOT VT? &nbsp;It can be difficult, but in this case, the rhythm, even though fast, is very irregular. &nbsp; VT is not always perfectly regular, but this irregularly-irregular rhythm points to atrial fibrillation. Also, the pattern of the QRS morphology fits with LBBB. &nbsp;The criteria for LBBB are: &nbsp;1) supraventricular rhythm, 2) wide QRS, 3) negative QRS in V1 with positive QRS in Leads I and V6. &nbsp;If we assume the rhythm is atrial fibrillation, we meet the first criteria. &nbsp;The other two are self-evident.</p><p>After the medication is administered, 10 minutes later, we see the rate slow down. &nbsp;There is no change in the irregularly-irregular rhythm, and the LBBB pattern remains. &nbsp;All that has changed is the rate and, hopefully, the patient's symptoms. &nbsp;This confirms that the original rhythm was not VT. &nbsp;</p><p>Remember, atrial fib lowers cardiac output because there is no P wave - no "atrial kick". &nbsp;Also, the fast rate associated with new-onset atrial fib often compromises ventricular filling and cardiac output. &nbsp; LBBB also has a deleterious effect on cardiac output. &nbsp;Wide QRS complexes indicate that the ventricles are not contracting efficiently and synchronously. &nbsp;The left ventricle is depolarizing by way of a slow wave of depolarization, rather than all the cells getting the message to depolarize at the same time. &nbsp;Having these two conditions at the same time can have a very negative effect on cardiac output, leading to CHF. &nbsp;The first step in treatment often involves simply slowing the rate to normal, which allows for better ventricular filling and decreases the workload on the heart. &nbsp;Then, the fibrillation and bundle branch block can be addressed.</p><p>There is some very slight variation in the QRS morphology in both of these ECGs. &nbsp;We will leave it to the more advanced Gurus to comment on this, and any other interesting features we may have missed.</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/436/feed" method="post" id="fivestar-custom-widget--6" 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--12" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Teaching Series: Atrial Fibrillation With Left Bundle Branch Block 1/5</option><option value="40">Give Teaching Series: Atrial Fibrillation With Left Bundle Branch Block 2/5</option><option value="60" selected="selected">Give Teaching Series: Atrial Fibrillation With Left Bundle Branch Block 3/5</option><option value="80">Give Teaching Series: Atrial Fibrillation With Left Bundle Branch Block 4/5</option><option value="100">Give Teaching Series: Atrial Fibrillation With Left Bundle Branch Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >2.9</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--6" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-UQwd-uLOS3LIIJMqRSsMDbK1cYb8OtabRXb0r4wBBZI" /> <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/left-bundle-branch-block-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left bundle branch block</a></div><div class="field-item odd"><a href="/ecg/lbbb" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">LBBB</a></div><div class="field-item even"><a href="/ecg/bundle-branch-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bundle branch block</a></div><div class="field-item odd"><a href="/ecg/teaching-series" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Teaching series</a></div><div class="field-item even"><a href="/ecg/wide-complex-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide complex tachycardia</a></div><div class="field-item odd"><a href="/ecg/atrial-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial fibrillation</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_6"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fteaching-series-atrial-fibrillation-left-bundle-branch-block&amp;title=Teaching%20Series%3A%20Atrial%20Fibrillation%20With%20Left%20Bundle%20Branch%20Block%20"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 30 May 2014 05:28:19 +0000 Dawn 577 at https://www.ecgguru.com https://www.ecgguru.com/ecg/teaching-series-atrial-fibrillation-left-bundle-branch-block#comments Teaching Tips: ECG Series WO 118: STEMI With Changing ST Elevations https://www.ecgguru.com/ecg/teaching-tips-ecg-series-wo-118-stemi-changing-st-elevations <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/teaching-tips-ecg-series-wo-118-stemi-changing-st-elevations"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW%20118%20A%20ECG%20No%201%20Field%20have%20cath%20Wolb.jpg" width="1800" height="656" alt="" /></a></div><div class="field-item odd"><a href="/ecg/teaching-tips-ecg-series-wo-118-stemi-changing-st-elevations"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW%20118%20B%20%20%20No%202%20Field%20have%20cath_0.jpg" width="1984" height="758" alt="" /></a></div><div class="field-item even"><a href="/ecg/teaching-tips-ecg-series-wo-118-stemi-changing-st-elevations"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW%20118%20C%20Emerg%20Dept_0.jpg" width="1800" height="1279" alt="" /></a></div><div class="field-item odd"><a href="/ecg/teaching-tips-ecg-series-wo-118-stemi-changing-st-elevations"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW%20118%20D%20%20ECG%20No%204%20Post%20Cath%20have%20cath_0.jpg" width="1800" height="1315" 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>Continuing with our theme of using &nbsp;series of ECGs for teaching, we present the case of an 83-year-old woman with weakness, chest pain, and near-syncope. &nbsp;The first ECG, taken by paramedics at her home, shows a sinus rhythm with a slightly wide QRS complex. &nbsp;At this point, it is unclear whether this represents left bundle branch block or a non-specific interventricular conduction delay. There is the most subtle ST elevation in Leads III and aVF. In LBBB without acute M.I., we would expect the ST segments to be discordant, or opposite, the QRS complexes. &nbsp; Even more informative is the<strong> reciprocal ST depression in Leads I and aVL</strong> (and a little in V2). &nbsp;This can be a sign of inferior wall injury that shows up earlier than ST elevation in the inferior leads.</p><p>ECG number 2 was taken during transport to the hospital. &nbsp;The chest pain continues, and now the ST elevation in the inferior leads is pronounced, and the reciprocal depression in I, aVL, and V2 has also become much more obvious. &nbsp;V1 would also normally show this depression - a sign of the injury traveling up the back of the inferior wall (posterior). &nbsp;But if the right ventricle is injured, V1 will have ST elevation. &nbsp; &nbsp;V1 in this case is probably reflecting the depression from the posterior wall AND the elevation from the right ventricle. &nbsp;The ST elevation is now prominent enough that the paramedics notified the hospital of a "STEMI Alert". &nbsp;The QRS remains widened at .13 sec., but the ST elevations and depressions are not opposite the QRS direction, which would be typical for LBBB without an M.I. &nbsp;Therefore, even if LBBB is present, these ST elevations and depressions would be considered a sign of STEMI. &nbsp;The rate is slowing in this ECG.</p><p>ECG number 3 was taken in the Emergency Department. &nbsp;The patient's symptoms continued. &nbsp;The bradycardia is still present, as is the QRS widening. &nbsp;Now, something new has shown up: &nbsp;prominent U waves in the precordial leads. &nbsp;There appears to be T-U fusion. &nbsp;We do not know the patient's medications or lab results, so the most likely cause for the prominent U waves is the bradycardia. &nbsp;She does not have other<a title="hypokalemia LITFL" href="http://lifeinthefastlane.com/ecg-library/basics/hypokalaemia/"> ECG signs of hypokalemia</a>, which is one of the many causes of U waves.&nbsp;</p><p>The patient was taken to the cath lab for angioplasty. &nbsp;In the cath lab, her right coronary artery was found to have several serious lesions, one of which was almost 100%. &nbsp;These lesions were stented. &nbsp;Often, when lesions are not completely occluding the artery, ST elevation can come and go. Arteries dilate and constrict, allowing more or less blood to flow past the partial occlusion. &nbsp;Changing arterial diameter, fluctuant thrombi, or increased/decreased myocardial oxygen demand can cause the ST segments to rise and fall. Changes in the nature of the chest pain can occur as well.</p><p>This ECG shows a continuing bradycardia (which may be affected by her medications), but her QRS has narrowed to .108 seconds (108 ms). &nbsp; Her inferior leads show a very slight coving upward of the ST segment, with T wave inversion, signs of evolution of the M.I. &nbsp;Unfortunately, pathological Q waves have formed in Leads III and aVF, which probably reflect permanent damage to the inferior wall. &nbsp;Followup ventriculograms or echocardiograms can establish LV function as time goes on. &nbsp;The good news is that the patient received good relief of her symptoms from the angioplasty procedure, and she did well to hospital discharge. &nbsp;We do not know about her condition post discharge. &nbsp;</p><p>To see images from this patient's RCA angioplasty, click<a title="WO 118 Angioplasty" href="http://ecgguru.com/ecg/patient-wo-118-angioplasty-right-coronary-artery"> HERE</a>.</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/436/feed" method="post" id="fivestar-custom-widget--7" 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--14" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Teaching Tips: ECG Series WO 118: STEMI With Changing ST Elevations 1/5</option><option value="40">Give Teaching Tips: ECG Series WO 118: STEMI With Changing ST Elevations 2/5</option><option value="60">Give Teaching Tips: ECG Series WO 118: STEMI With Changing ST Elevations 3/5</option><option value="80">Give Teaching Tips: ECG Series WO 118: STEMI With Changing ST Elevations 4/5</option><option value="100" selected="selected">Give Teaching Tips: ECG Series WO 118: STEMI With Changing ST Elevations 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >5</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--7" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-Hz61EY-98ziVOJH7MxAYMqGm1ZjFv10UX8J4tnfkUMk" /> <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/teaching-series" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Teaching series</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</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></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_7"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fteaching-tips-ecg-series-wo-118-stemi-changing-st-elevations&amp;title=Teaching%20Tips%3A%20%20%20%20ECG%20Series%20WO%20118%3A%20%20%20%20STEMI%20With%20Changing%20ST%20Elevations"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 24 Jan 2014 05:15:21 +0000 Dawn 547 at https://www.ecgguru.com https://www.ecgguru.com/ecg/teaching-tips-ecg-series-wo-118-stemi-changing-st-elevations#comments