ECG Guru - Instructor Resources - Sinus bradycardia https://www.ecgguru.com/ecg/sinus-bradycardia en Sinus Bradycardia and More https://www.ecgguru.com/blog/sinus-bradycardia-and-more <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/sinus-bradycardia-and-more"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/sinusbrady.jpeg" width="1200" height="758" alt="" /></a></div><div class="field-item odd"><a href="/blog/sinus-bradycardia-and-more"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/expl.jpg" width="2597" height="1764" 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>Let's analyze the ECG. It comes from a pacemaker patient whose pacemaker was briefly switched to VVI at 30 bpm due to a stimulation threshold test. The first 3 beats show a sinus rhythm with a frequency of approx. 40 bpm. This is followed by a premature ventricular contraction (PVC). The P wave of the next sinus node beat lands exactly on the T of the PVC. This cannot be conducted to the ventricles, either because the ventricular myocardium is still unexcitable or the PVC has conducted retrogradely into the AV node and this is therefore still refractory. This is followed by an artifact that should not be confused with a P wave. The next beat is a junctional escape beat (the QRS complexes are identical to the sinus node beats). A sinus rhythm is then established again (sinus bradycardia). The inverted T waves (in II, III and aVF) are to be interpreted as <strong>cardiac memory,</strong>&nbsp;which refers to T wave inversions that result when normal ventricular activation resumes after a period of abnormal ventricular activation.</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/66/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 Sinus Bradycardia and More 1/5</option><option value="40">Give Sinus Bradycardia and More 2/5</option><option value="60">Give Sinus Bradycardia and More 3/5</option><option value="80">Give Sinus Bradycardia and More 4/5</option><option value="100" selected="selected">Give Sinus Bradycardia and More 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 >1</span> vote)</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-iYXXmNrVbga5QBPoOv0m3nH6UqKX1jHo_tFXTX7aAYU" /> <input type="hidden" name="form_id" 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_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fblog%2Fsinus-bradycardia-and-more&amp;title=Sinus%20Bradycardia%20and%20More"><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> Mon, 20 Nov 2023 09:40:39 +0000 Dr A Röschl 881 at https://www.ecgguru.com https://www.ecgguru.com/blog/sinus-bradycardia-and-more#comments Left Bundle Branch Block https://www.ecgguru.com/ecg/left-bundle-branch-block-4 <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/left-bundle-branch-block-4"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LB119.jpg" width="1800" height="1322" alt="" /></a></div><div class="field-item odd"><a href="/ecg/left-bundle-branch-block-4"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LB119%20Lead%20II%20P%20wave.jpg" width="152" height="137" alt="" /></a></div><div class="field-item even"><a href="/ecg/left-bundle-branch-block-4"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LB119%20Lead%20V1%20P%20wave.jpg" width="211" height="226" 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">This ECG is taken from an elderly man with heart failure.<span style="mso-spacerun: yes;">&nbsp; </span></p><p class="MsoNormal"><strong><span style="color: #00b050;">The ECG <span style="mso-spacerun: yes;">&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span></span></strong>The first feature that might capture your attention is the wider-than-normal QRS complex, which is 160 ms (.16 seconds).<span style="mso-spacerun: yes;">&nbsp; </span>The rate is 58 bpm. We do not know the patient’s medications or baseline rate.<span style="mso-spacerun: yes;">&nbsp; </span>There are P waves present, and so the rhythm is <strong>SINUS BRADYCARDIA. </strong>The P waves are broad , &gt; 110 ms in Lead II (red lines in close up) and bifid, with greater than 40 ms between the two peaks in Lead II (blue lines).<span style="mso-spacerun: yes;">&nbsp; </span>In V1, the P waves are biphasic, with the terminal negative portion greater than 40 ms duration (red lines). This meets the ECG criteria for <strong>LEFT ATRIAL ENLARGEMENT, or preferably, LEFT ATRIAL ABNORMALITY</strong>. (<a href="https://litfl.com/left-atrial-enlargement-ecg-library/">https://LITFL.com/left-atrial-enlargement-ecg-library/</a>) ECG criteria are not highly accurate for detecting atrial enlargement, and abnormal findings should be confirmed by anatomic measurement. (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2244611/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2244611/</a>).</p><p class="MsoNormal">The QRS complexes, as mentioned, are wide. Because there is sinus rhythm, we know the delay in conduction is due to interventricular conduction delay, and not to ventricular rhythm.<span style="mso-spacerun: yes;">&nbsp; </span>This ECG meets the criteria for <strong>LEFT BUNDLE BRANCH BLOCK.<span style="mso-spacerun: yes;">&nbsp; </span></strong></p><p class="MsoListParagraphCxSpFirst" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol; mso-bidi-font-weight: bold;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->Supraventricular rhythm<span style="mso-spacerun: yes;">&nbsp; </span><strong></strong></p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol; mso-bidi-font-weight: bold;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->Wide QRS (<span style="text-decoration: underline;">&gt;</span>.12 seconds)<strong></strong></p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol; mso-bidi-font-weight: bold;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->Upright QRS in Leads I and V6<strong></strong></p><p class="MsoListParagraphCxSpLast" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol; mso-bidi-font-weight: bold;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->Negative QRS in Lead V1.<strong></strong></p><p class="MsoNormal">Both left atrial abnormalities and left bundle branch are associated with &nbsp;heart failure. The leftward axis at -39 degrees is commonly seen with left bundle branch block.</p><p class="MsoNormal">The ST segment elevation in V1 through V4 is normally seen in LBBB.<span style="mso-spacerun: yes;">&nbsp; </span>The amount of elevation will be associated with the depth of the negative QRS complex.<span style="mso-spacerun: yes;">&nbsp; </span>That is, the deeper the QRS, the higher the STE will be.<span style="mso-spacerun: yes;">&nbsp; </span>ST segments and T wave size and shape can be altered by LBBB.<span style="mso-spacerun: yes;">&nbsp; </span>If a patient with LBBB has symptoms of acute coronary insufficiency, further evaluation is warranted.<span style="mso-spacerun: yes;">&nbsp; </span>On the topic of LBBB and acute M.I., the <a href="https://wikem.org/wiki/Sgarbossa%27s_criteria">Smith-Modified Sgarbossa Criteria</a> should be reviewed, as it is one of the most accurate predictors of acute coronary occlusion in the patient with LBBB.</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/66/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 Left Bundle Branch Block 1/5</option><option value="40">Give Left Bundle Branch Block 2/5</option><option value="60">Give Left Bundle Branch Block 3/5</option><option value="80" selected="selected">Give Left Bundle Branch Block 4/5</option><option value="100">Give 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 >3.3</span></span> <span class="total-votes">(<span >69</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-AIrzpBInHuaHxkzi6Q4BDv25Xj3kP8uPqRdZVO_AH6o" /> <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/p-mitrale" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">P mitrale</a></div><div class="field-item odd"><a href="/ecg/left-atrial-abnormality" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left atrial abnormality</a></div><div class="field-item even"><a href="/ecg/left-atrial-enlargement" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left atrial enlargement</a></div><div class="field-item odd"><a href="/ecg/sinus-bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus bradycardia</a></div><div class="field-item even"><a href="/ecg/smith-modified-sgarbossa-criteria-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Smith-modified Sgarbossa Criteria</a></div><div class="field-item odd"><a href="/ecg/bundle-branch-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bundle branch 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%2Fleft-bundle-branch-block-4&amp;title=Left%20Bundle%20Branch%20Block"><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 Aug 2021 21:08:19 +0000 Dawn 799 at https://www.ecgguru.com https://www.ecgguru.com/ecg/left-bundle-branch-block-4#comments High-grade AV Block With Profound Bradycardia https://www.ecgguru.com/ecg/high-grade-av-block-profound-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/high-grade-av-block-profound-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB120%20High%20grade%20w%20sinus%20brady.jpg" width="1800" height="768" 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">If you are an ECG instructor, you probably carefully choose ECGs to illustrate the topic you are teaching. One of the reasons for the existence of the ECG Guru website is our desire to provide lots of such illustrations for you to choose from.</p><p class="MsoNormal">Sometimes, though, an ECG does not clearly illustrate one specific dysrhythmia well, because the interpretation of the ECG depends on so many other factors.<span style="mso-spacerun: yes;">&nbsp; </span>In order to get it “right”, we would need to know information about the patient’s history, presentation, lab results, or previous ECGs. We might need to see the ECG done immediately before or after the one we are looking at.<span style="mso-spacerun: yes;">&nbsp; </span>Some ECG findings must ultimately be confirmed by an electrophysiology study before we can know for sure what is going on.</p><p class="MsoNormal">For those of us who are “ECG nerds”, it can be fun to debate our opinions and even more fun to hear from wiser, more advanced practitioners about their interpretations.</p><p class="MsoNormal">My belief, as a clinical instructor, is that we must teach strategies for treating the patient who has a “controversial” ECG that take into account the level of the practitioner, the care setting, and the patient’s hemodynamic status.<span style="mso-spacerun: yes;">&nbsp; </span>In some settings, it might be absolutely forbidden for a first-responder to cardiovert atrial fibrillation, for example.<span style="mso-spacerun: yes;">&nbsp; </span>But atrial fib is routinely cardioverted under controlled conditions in hospitals.<span style="mso-spacerun: yes;">&nbsp; </span>The general rule followed by emergency providers that “all wide-complex tachycardias are v tach until proven otherwise” has no doubt prevented deaths in situations where care providers did not agree on the origin of the tachycardia.</p><p class="MsoNormal"><strong><span style="color: #00b050;">The ECG: <span style="mso-spacerun: yes;">&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span></span></strong>We do not have much patient information to go with this ECG, just that it is from a 71-year-old woman who developed severe hypotension and lost consciousness, but was revived with transcutaneous pacing.<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>Here is what we do know about this ECG:</p><p class="MsoListParagraphCxSpFirst" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="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; </span></span></span><!--[endif]-->There are regular P waves, at a rate of about 39 bpm (sinus bradycardia).</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="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; </span></span></span><!--[endif]-->There are only two QRS complexes, shown in a total of six leads, and the rate is 13 bpm.</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="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; </span></span></span><!--[endif]-->The two PR intervals that are seen are the same at 368 ms, or .368 seconds (first-degree AVB).</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="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; </span></span></span><!--[endif]-->There are three P waves for every QRS complex. (second-degree AVB, Type II).</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="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; </span></span></span><!--[endif]-->The QRS complexes are 144 ms wide (.14 seconds).</p><p class="MsoListParagraphCxSpLast" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="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; </span></span></span><!--[endif]-->The QRS morphology cannot be evaluated in 12 leads here, but the pattern is consistent with right bundle branch block and left anterior fascicular block (bifascicular block).<span style="mso-spacerun: yes;">&nbsp; </span>Were we at the bedside, another 10 seconds of 12-lead ECG might produce a QRS that falls into the remaining leads’ sections of the tracing.</p><p class="MsoNormal">It would be very important to determine what caused the severe slowing of conduction. The paper speed has not been altered, and that should be ruled out whenever all rates and intervals are prolonged.<span style="mso-spacerun: yes;">&nbsp; </span>The severe sinus bradycardia, second-degree AVB, first-degree AVB, and bundle branch block all point to a global cause of poor conduction.<span style="mso-spacerun: yes;">&nbsp; </span>Electrolytes, drugs, vagal stimulation, possible acute M.I. – all of these need to be assessed.<span style="mso-spacerun: yes;">&nbsp; </span>And, eventually, the best definitive treatment will need to be decided.</p><p class="MsoNormal">But what is the <strong>MOST IMPORTANT </strong>issue here?<span style="mso-spacerun: yes;">&nbsp; </span><strong><span style="color: #c00000;">The RATE!</span></strong><span style="color: #c00000;"><span style="mso-spacerun: yes;">&nbsp; </span></span>And the patient’s response to the extremely slow rate.<span style="mso-spacerun: yes;">&nbsp; </span>Before we spend any time on the cause or treatment, we must address the rate and the patient’s hemodynamic status.<span style="mso-spacerun: yes;">&nbsp; </span>A transcutaneous pacemaker, if available, is called for.<span style="mso-spacerun: yes;">&nbsp; </span>CPR may be needed until the pacemaker can provide a perfusing rate. Rate-enhancing drugs may be used, and temporary transvenous pacing.<span style="mso-spacerun: yes;">&nbsp; </span>If the patient’s perfusion status is not addressed, the rest will not matter.</p><p class="MsoNormal">When students are taking an ECG class, they most often want to know, “what is the name of this rhythm?” and “what are some shortcuts or mnemonics I can use to remember the names of the rhythms?”.<span style="mso-spacerun: yes;">&nbsp; </span>They will be distressed if the instructor says, “This could be second-degree AVB, or we could call it high-grade AVB, or a longer strip might show it to be third-degree AVB.”<span style="mso-spacerun: yes;">&nbsp; </span>The instructor may even feel distressed by not knowing “for sure.”<span style="mso-spacerun: yes;">&nbsp; </span>But (and this is admittedly an editorial on my part), I think we do our students a disservice to lead them to believe that there is a “right” answer to every ECG strip. They need to know that some ECGs cannot and should not be read in a vacuum, but rather in light of the patient’s information. They need to know that comparison with a previous ECG, or adding additional leads, or running a longer strip may illuminate the problem.<span style="mso-spacerun: yes;">&nbsp; </span>But most of all, they should understand what immediate actions can safely be taken until we do “know for sure”.</p><p class="MsoNormal">We welcome your comments on this topic, whether you are a teacher, a student, a provider, or all of these.</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/66/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 High-grade AV Block With Profound Bradycardia 1/5</option><option value="40">Give High-grade AV Block With Profound Bradycardia 2/5</option><option value="60">Give High-grade AV Block With Profound Bradycardia 3/5</option><option value="80" selected="selected">Give High-grade AV Block With Profound Bradycardia 4/5</option><option value="100">Give High-grade AV Block With Profound Bradycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.5</span></span> <span class="total-votes">(<span >27</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-0WK19qkx7hNGx3p2HxuSvK55CiS-x_GnLKxE4etIXco" /> <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/high-grade-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">High-grade AV Block</a></div><div class="field-item odd"><a href="/ecg/sinus-bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus bradycardia</a></div><div class="field-item even"><a href="/ecg/second-degree-av-block-type-ii" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Second-degree AV block Type II</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-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/bifascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bifascicular block</a></div><div class="field-item odd"><a href="/ecg/first-degree-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">First-degree AV 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_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fhigh-grade-av-block-profound-bradycardia&amp;title=High-grade%20AV%20Block%20With%20Profound%20Bradycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 04 Jun 2020 20:24:18 +0000 Dawn 785 at https://www.ecgguru.com https://www.ecgguru.com/ecg/high-grade-av-block-profound-bradycardia#comments Bifascicular Block and Sinus Bradycardia https://www.ecgguru.com/ecg/bifascicular-block-and-sinus-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/bifascicular-block-and-sinus-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/RBLAH103%20%20from%20Andrea.jpg" width="1800" height="949" 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">Today’s ECG is from a 75 year old man who has been experiencing syncope.<span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal">Examination of the ECG shows a sinus bradycardia at just under 40 bpm.&nbsp; There is a first-degree AV block, with a PR interval of about .28 seconds (280 ms).&nbsp; There is a right bundle branch block.&nbsp; The ECG criteria for right bundle branch block are: &nbsp;supraventricular rhythm, wide QRS (120 ms in this case), rSR’ pattern in V1, and &nbsp;a small, wide S wave in Leads I and V6.&nbsp; There is actually a “terminal delay”, or extra wave at the end of each QRS complex, reflecting late repolarization of the right ventricle.<span style="font-size: 13.008px;">&nbsp;</span></p><p class="MsoNormal">This ECG also shows a left anterior fascicular block, also called left anterior hemiblock.&nbsp; The left bundle branch usually has two main branches, the anterior-superior and the posterior-inferior.&nbsp; ECG criteria for left anterior fascicular block are: left axis deviation with a small r wave in Lead III and a small q waves with tall R waves in Leads I and aVL. &nbsp;There is also a prolonged R wave peak time (&gt; 45 ms) in aVL. There is usually a slightly prolonged QRS, but in this case, there is widening of the QRS due to the RBBB. &nbsp; Because the right bundle branch is blocked, and one fascicle of the left bundle is blocked, the patient is said to have a “bifascicular block”.&nbsp; Only one fascicle remains available for conduction from the atria to the ventricles.</p><p class="MsoNormal">We have no information about what caused the conduction block in these two fascicles, but should the third fascicle fail, the patient will be in a complete AV block.&nbsp; An AV block at the level of the bundle branches will result in an idioventricular escape rhythm – wide QRS complexes with very slow rates – which is a low-output rhythm.<span style="font-size: 13.008px;">&nbsp;</span><span style="font-size: 13.008px;">&nbsp;</span></p><p class="MsoNormal">This patient has also had syncope, which was determined to be related to his bradycardia.&nbsp; He had an AV sequential pacemaker implanted and did well.</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/66/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 and Sinus Bradycardia 1/5</option><option value="40">Give Bifascicular Block and Sinus Bradycardia 2/5</option><option value="60">Give Bifascicular Block and Sinus Bradycardia 3/5</option><option value="80" selected="selected">Give Bifascicular Block and Sinus Bradycardia 4/5</option><option value="100">Give Bifascicular Block and Sinus Bradycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.7</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--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-mzn8RM6lCExfF3P4xfmxnbynhKAAHvL41cgEBndkDzs" /> <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-bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus bradycardia</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-anterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior hemiblock</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/st-and-t-wave-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST and T wave changes</a></div><div class="field-item odd"><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 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></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-and-sinus-bradycardia&amp;title=%20Bifascicular%20Block%20and%20Sinus%20Bradycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 19 Nov 2016 02:30:23 +0000 Dawn 716 at https://www.ecgguru.com https://www.ecgguru.com/ecg/bifascicular-block-and-sinus-bradycardia#comments ECG Basics: Sinus Bradycardia https://www.ecgguru.com/ecg/ecg-basics-sinus-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/ecg-basics-sinus-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/161Sinus%20brady.jpg" width="2037" 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>Sinus bradycardia. &nbsp;This strip meets the criteria of: &nbsp;regular rhythm, rate less than 60 bpm (40 bpm in this case), regular P waves before every QRS. &nbsp;Sinus bradycardia can have many causes from a completely normal variation to a malfunction of the sinus node. &nbsp;In some cases, enhanced parasympathetic tone causes sinus bradycardia. &nbsp;Well-conditioned athletes typically have sinus bradycardia. Treatment depends upon the cause and the patient's response to the rate. &nbsp;If the rate does not cause hemodynamic impairment, treatment may not be necessary.</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/66/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: Sinus Bradycardia 1/5</option><option value="40">Give ECG Basics: Sinus Bradycardia 2/5</option><option value="60">Give ECG Basics: Sinus Bradycardia 3/5</option><option value="80" selected="selected">Give ECG Basics: Sinus Bradycardia 4/5</option><option value="100">Give ECG Basics: Sinus Bradycardia 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 >5</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-TdzXbQj8uv9LBk4dfDqdpyLSHuCvR6-B1zbDNQqZuBk" /> <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-bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus bradycardia</a></div><div class="field-item odd"><a href="/ecg/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</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/basic-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Basic ECG</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-sinus-bradycardia&amp;title=ECG%20Basics%3A%20%20Sinus%20Bradycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 14 Aug 2016 05:56:14 +0000 Dawn 708 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-sinus-bradycardia#comments Electrolyte Effects https://www.ecgguru.com/ecg/electrolyte-effects <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/electrolyte-effects"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/DE102.jpg" width="1800" height="1239" 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: 13.008px; line-height: 1.538em;">This ECG is from a 46-year-old woman with diabetes mellitus.</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp; </span><span style="font-size: 13.008px; line-height: 1.538em;">She presented to the Emergency Dept. with a complaint of weakness.</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp; </span><span style="font-size: 13.008px; line-height: 1.538em;">Her BP was elevated at 186/102.</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp; </span><span style="font-size: 13.008px; line-height: 1.538em;">Her blood glucose was 936 mg/dL (normal 70-105).</span>&nbsp;</p><p class="MsoNormal"><strong><span style="color: green;">So, what does her ECG show?</span></strong></p><p class="MsoNormal"><strong></strong><span style="font-size: 13.008px; line-height: 1.538em;">1) Sinus bradycardia at 55 bpm.</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp; </span><span style="font-size: 13.008px; line-height: 1.538em;">The rhythm is regular, with no extrasystoles.</span></p><p class="MsoNormal"><span style="font-size: 13.008px; line-height: 1.538em;">2) A slightly prolonged PR interval at 218 ms (.218 seconds). Normal is 120-200 ms.</span>&nbsp;</p><p class="MsoNormal">3) A “wide side of normal” QRS duration at 109 ms. Normal is 70-100, but can be a little longer in normal i<span style="font-size: 13.008px; line-height: 1.538em;">ndividuals.</span></p><p class="MsoNormal">4) A prolonged QTc interval at 520 ms.&nbsp; Normal QTc is 460 ms or less in women. A helpful rule of thumb i<span style="font-size: 13.008px; line-height: 1.538em;">s that the QT should be less than half the preceding RR.</span>&nbsp;</p><p class="MsoNormal">5) Normal P waves.</p><p class="MsoNormal">6) Normal axes of P, QRS, and T waves.</p><p class="MsoNormal">7) A large Q wave in Lead III which is not repeated in aVL.&nbsp; This can be inconsequential when confined to&nbsp;<span style="font-size: 13.008px; line-height: 1.538em;">Lead III, or can be a pathological Q wave, especially if also seen in aVF.</span>&nbsp;</p><p class="MsoNormal">8) Flat ST segments.&nbsp; Normal ST segments are convex upward, like a smile.</p><p class="MsoNormal">9) Tall, peaked T waves in precordial leads V<sub>2</sub> through V<sub>6</sub>, and in Lead II.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="color: green;">What does it mean?</span></strong></p><p class="MsoNormal">Unfortunately, we do not have complete labs for this patient, or any information about her outcome.</p><p class="MsoNormal">We know that patients who have uncontrolled diabetes are at risk for renal failure, so we should consider electrolyte imbalances when we see abnormalities in the ECG.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The prolonged, flat ST segment is suggestive of <strong><a href="http://lifeinthefastlane.com/ecg-library/basics/ecg-features-of-hypocalcaemia/">HYPOCALCEMIA</a></strong>.&nbsp; The low-amplitude P waves and tall, peaked T waves suggest <strong><a href="http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/">HYPERKALEMIA</a>.&nbsp; </strong>&nbsp;You will find a discussion of simultaneous hypocalcemia and hyperkalemia on this website <a href="http://ecgguru.com/blog/jasons-blog-ecg-challenge-week-june-17-24-what-highs-and-lows-tracing-suggestive/">HERE</a>.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span>&nbsp;</p><p class="MsoNormal">We are looking forward to your comments.</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/66/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 Electrolyte Effects 1/5</option><option value="40">Give Electrolyte Effects 2/5</option><option value="60">Give Electrolyte Effects 3/5</option><option value="80" selected="selected">Give Electrolyte Effects 4/5</option><option value="100">Give Electrolyte Effects 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 >7</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-an1mL-gCCnE4OTtoW63-W4wjbV83FVa0EtK3KqJwr-A" /> <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/hyperkalemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperkalemia</a></div><div class="field-item odd"><a href="/ecg/hypocalcemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hypocalcemia</a></div><div class="field-item even"><a href="/ecg/prolonged-qt-interval" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Prolonged QT interval</a></div><div class="field-item odd"><a href="/ecg/sinus-bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus bradycardia</a></div><div class="field-item even"><a href="/ecg/peaked-t-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Peaked T waves</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%2Felectrolyte-effects&amp;title=Electrolyte%20Effects"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 12 Jul 2016 22:00:34 +0000 Dawn 706 at https://www.ecgguru.com https://www.ecgguru.com/ecg/electrolyte-effects#comments Inferior Wall M.I. https://www.ecgguru.com/ecg/inferior-wall-mi-2 <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/inferior-wall-mi-2"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW119.jpg" width="1800" height="883" 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" align="left">This ECG shows a common manifestation with inferior wall M.I., BRADYCARDIA.&nbsp; We see the signs of acute inferior wall M.I. in the inferior leads:&nbsp; II, III, and aVF all have ST segment elevation.&nbsp; There almost appear to be pathological Q waves in Leads III and aVF.&nbsp; There are still VERY tiny r waves, and the downward deflections are not wide, but should full-blown Q waves develop in these leads, they would signify necrosis in the area.&nbsp; A repeat ECG would certainly be warranted.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">Another sign that there is an inferior wall STEMI is the ST segment depression in Leads I and aVL, which are reciprocal to Lead III.&nbsp; ST depression can have many meanings, but when it is <strong>localized</strong> in the leads which are opposite ST elevation, it is reciprocal.&nbsp; There is also ST depression in Leads V1 and V2.&nbsp; These leads are reciprocal to the POSTERIOR wall, otherwise known as the upper part of the inferior wall.&nbsp; If an inferior wall M.I. is large enough, it can produce ST elevation in the posterior leads (not performed in this case), and ST depression in the anterior leads, especially V1, V2, and V3.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">The rhythm is a marked sinus bradycardia, at just under 40 beats per minute.&nbsp; Sinus bradycardia is very common in inferior wall M.I., because the inferior wall and the sinus node are usually both supplied by the right coronary artery.&nbsp; AV blocks can also occur because the AV node is also supplied by the RCA in most people.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">It is important to remember that bradycardia does not always need to be treated.&nbsp; In patients with acute M.I., a well-tolerated bradycardia may actually be beneficial to the injured heart, reducing supply/demand ischemia.&nbsp; A well-tolerated bradycardia is a rate that does not produce low blood pressure and poor peripheral perfusion.&nbsp; Some people tolerate rates in the 40’s quite well.&nbsp; If the patient shows signs of poor perfusion: low BP, decreased mentation, pallor, shortness of breath, the rate should be cautiously increased with medication or electronic pacing.&nbsp;<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p>&nbsp;</p><p class="MsoNormal" align="left">Patients who present with acute inferior wall M.I. should be screened for right ventricular M.I.&nbsp; Right-sided chest leads, especially V3 through V6 can reliably detect right ventricular M.I.&nbsp; Other signs which may or may not be present, and have less accuracy, are:&nbsp; Lead III with higher ST elevation than Lead II, aVL with ST depression of 1 mm or more, and ST elevation in V1 on the 12-Lead ECG. &nbsp;For more about the prognostic implications and treatment of RVMI, we refer you to <a href="http://www.consultant360.com/content/inferior-myocardial-infarction-right-ventricular-involvement">Drs. Wang and Poponick.</a></p><p class="MsoNormal" align="left">For a more detailed look at this ECG, and a thorough discussion of inferior wall M.I. ECG changes, please refer to the comment below from our Consulting Expert, Dr. Ken Grauer, MD.</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/66/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 Inferior Wall M.I. 1/5</option><option value="40">Give Inferior Wall M.I. 2/5</option><option value="60">Give Inferior Wall M.I. 3/5</option><option value="80" selected="selected">Give Inferior Wall M.I. 4/5</option><option value="100">Give Inferior Wall M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.6</span></span> <span class="total-votes">(<span >5</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-4YaGzgKCI2sHsgxcOfQYQ6UTosVqF7MwC4cvN9wD3no" /> <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/inferior-wall-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior Wall M.I.</a></div><div class="field-item odd"><a href="/ecg/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</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/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</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/sinus-bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus 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_7"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-wall-mi-2&amp;title=Inferior%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> Tue, 17 Nov 2015 20:38:04 +0000 Dawn 677 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-wall-mi-2#comments ECG Basics: Sinus Bradycardia With A Premature Atrial Contraction https://www.ecgguru.com/ecg/ecg-basics-sinus-bradycardia-premature-atrial-contraction <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-bradycardia-premature-atrial-contraction"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/138%20Sinus%20brady%20with%20PAC.jpg" width="1800" height="215" 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 strip shows an underlying sinus bradycardia with a rate less than 40/min. &nbsp;There is one "premature" beat, which can be considered to be ectopic, because it interrupts an otherwise regular rhythm. &nbsp;The interesting thing is that the premature beat is not terribly early - it is about 740 ms from the previous beat. &nbsp;If all the beats were spaced like this, the heart rate would be about 84/min. &nbsp;There is probably an element of "escape" here, in that the ectopic beat is able to express itself due to the slow rate. &nbsp;A faster sinus rate would override this ectopic focus. &nbsp;So, we could view this early beat as a help, rather than a problem. &nbsp;The most important consideration here is to address the cause of the bradycardia, and treat appropriately.&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/66/feed" method="post" id="fivestar-custom-widget--8" 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--16" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give ECG Basics: Sinus Bradycardia With A Premature Atrial Contraction 1/5</option><option value="40">Give ECG Basics: Sinus Bradycardia With A Premature Atrial Contraction 2/5</option><option value="60">Give ECG Basics: Sinus Bradycardia With A Premature Atrial Contraction 3/5</option><option value="80">Give ECG Basics: Sinus Bradycardia With A Premature Atrial Contraction 4/5</option><option value="100" selected="selected">Give ECG Basics: Sinus Bradycardia With A Premature Atrial Contraction 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 >4</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--8" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-PxBiPV_iQScyhWelEIKlUCOT5LpEeztkF6qiCoiB7IM" /> <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-bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus bradycardia</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/premature-atrial-contraction" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Premature atrial contraction</a></div><div class="field-item odd"><a href="/ecg/pac" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PAC</a></div><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></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_8"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fecg-basics-sinus-bradycardia-premature-atrial-contraction&amp;title=ECG%20Basics%3A%20Sinus%20Bradycardia%20With%20A%20Premature%20Atrial%20Contraction"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 14 Apr 2015 03:45:34 +0000 Dawn 634 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-sinus-bradycardia-premature-atrial-contraction#comments Jason's Blog: ECG Challenge for the month of April, 2014. https://www.ecgguru.com/blog/jasons-blog-ecg-challenge-month-april-2014 <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-april-2014"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/ECG%20of%20the%20Month%203c%20ladder%20diagram.png" width="788" height="509" 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><span style="text-decoration: underline;"><strong>Patient data:</strong></span>&nbsp; 62-year old man.</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/66/feed" method="post" id="fivestar-custom-widget--9" 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--18" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Jason&amp;#039;s Blog: ECG Challenge for the month of April, 2014. 1/5</option><option value="40">Give Jason&amp;#039;s Blog: ECG Challenge for the month of April, 2014. 2/5</option><option value="60">Give Jason&amp;#039;s Blog: ECG Challenge for the month of April, 2014. 3/5</option><option value="80" selected="selected">Give Jason&amp;#039;s Blog: ECG Challenge for the month of April, 2014. 4/5</option><option value="100">Give Jason&amp;#039;s Blog: ECG Challenge for the month of April, 2014. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.3</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--9" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-zx1CBIe2iNbSS5ToiiWCukIoy46jNXJnOhr2bxCQ0fQ" /> <input type="hidden" name="form_id" 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_9"> <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-april-2014&amp;title=Jason%27s%20Blog%3A%20ECG%20Challenge%20for%20the%20month%20of%20April%2C%202014."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Mon, 31 Mar 2014 00:18:25 +0000 jer5150 565 at https://www.ecgguru.com https://www.ecgguru.com/blog/jasons-blog-ecg-challenge-month-april-2014#comments ECG Basics: Sinus Bradycardia With First-degree AV Block https://www.ecgguru.com/ecg/ecg-basics-sinus-bradycardia-first-degree-av-block-0 <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-bradycardia-first-degree-av-block-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/126%20Sinus%20brady%20c%201st%20degree%20AVB.jpg" width="1800" height="260" 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 nice teaching strip of a slowing sinus bradycardia that began around 40 bpm, and is slowing. &nbsp;It is a good example of how the sinus node slows down - there is no abrupt change of rates, rather a change with each R-to-R interval. &nbsp;There is also a first-degree AV block, reflecting slowing of conduction in the AV node. &nbsp;The PR interval is slightly variable at .28 sec. to about .32 sec. &nbsp;This is a good strip to begin talking about treatment of bradycardias with beginner students, as there is no second- or third-degee AVB, but the patient is very likely to be symptomatic now, or very soon. &nbsp;Atropine would probably improve this rate in a symptomatic patient, but if there is time, a 12-Lead would be a good idea to rule out acute M.I. &nbsp;Inadvertently raising the rate too much in the injured heart can lead to pump failure, while leaving the patient poorly-perfused in a bradycardia will starve the heart. &nbsp;A transthoracic or temporary IV pacemaker might be a better choice for some patients because of our ability to choose the rate.</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/66/feed" method="post" id="fivestar-custom-widget--10" 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--20" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give ECG Basics: Sinus Bradycardia With First-degree AV Block 1/5</option><option value="40">Give ECG Basics: Sinus Bradycardia With First-degree AV Block 2/5</option><option value="60">Give ECG Basics: Sinus Bradycardia With First-degree AV Block 3/5</option><option value="80">Give ECG Basics: Sinus Bradycardia With First-degree AV Block 4/5</option><option value="100">Give ECG Basics: Sinus Bradycardia With First-degree AV Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="empty">No votes yet</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--10" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-y-ciJFyT5dsDu-495WAMI-35JxwAedey_9iPmY4HgVg" /> <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/first-degree-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">First-degree AV block</a></div><div class="field-item even"><a href="/ecg/sinus-bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus bradycardia</a></div><div class="field-item odd"><a href="/ecg/long-pr-interval" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Long PR interval</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_10"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fecg-basics-sinus-bradycardia-first-degree-av-block-0&amp;title=ECG%20Basics%3A%20Sinus%20Bradycardia%20With%20First-degree%20AV%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 10 Jan 2014 21:52:59 +0000 Dawn 540 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-sinus-bradycardia-first-degree-av-block-0#comments