ECG Guru - Instructor Resources - Bigeminy https://www.ecgguru.com/ecg/bigeminy en Atrial Bigeminy Vs Possible Sino-atrial Exit Block https://www.ecgguru.com/ecg/instructors-collection-ecg-week-october-5-2015-sino-atrial-exit-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/instructors-collection-ecg-week-october-5-2015-sino-atrial-exit-block-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/MR%20115%202ndDeg%20SA%20block%20Type%20II_0.jpg" width="3278" height="2289" alt="" /></a></div><div class="field-item odd"><a href="/ecg/instructors-collection-ecg-week-october-5-2015-sino-atrial-exit-block-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/MR%20115%20Laddergram%20jpg.jpg" width="3507" height="2550" 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 three-lead rhythm strip is from an 85 year-old-woman for whom we have no other information, unfortunately.&nbsp; It shows an obvious, regular bigeminal pattern.&nbsp; There are many rhythms that can cause bigeminy, with regular, paired beats.&nbsp; So, how do we analyze this rhythm?<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">First, we can see that all the QRS complexes are fairly narrow and look alike in each lead.&nbsp; So, we know this is a supraventricular rhythm.&nbsp; The rhythm “marches out”, with the same spacing between all the paired beats, and exactly one P-QRS missing after each pair.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">Sino-atrial exit block occurs when the sinus node fires, but the impulse is unable to exit the sinus node. No P wave will occur, but the sinus node continues to fire in a regular rhythm.&nbsp; There are four types of SA block, just as there are four types of AV block.&nbsp; <strong>This ECG meets the criteria for a Second-degree, Type II SA block.</strong><strong style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</strong></p><p class="MsoNormal" align="left"><strong>First-degree SA block</strong> would not be decipherable on the ECG, as we do not see the SA node fire, and therefore cannot measure an interval between the SA node firing and the production of a P wave.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left"><strong>Second-degree SA block, Type I</strong> would have progressively prolonging exit times for the impulse leaving the SA node. &nbsp;<span style="font-size: 13.008px; line-height: 1.538em;">This would produce </span><strong style="font-size: 13.008px; line-height: 1.538em;">progressively shortening R-to-R intervals</strong><span style="font-size: 13.008px; line-height: 1.538em;">, until the pause.</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left"><strong>Second-degree SA block, Type II</strong> has <strong>regular R-to-R intervals until the pause</strong>, and the pause will equal two or more (usually two) R-to-R intervals.&nbsp;</p><p class="MsoNormal" align="left"><strong style="font-size: 13.008px; line-height: 1.538em;">Third-degree SA block</strong><span style="font-size: 13.008px; line-height: 1.538em;"> produces NO P WAVES, and would have to be diagnosed on electrophysiology studies, as it would usually result in a junctional escape rhythm.</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">Differential diagnosis includes many causes of “atrial bigeminy”.&nbsp; When every other beat is a premature atrial contraction (APB or PAC), the pause will be caused by the PAC “re-setting” the sinus node, and will not be a multiple of the R-to-R interval on that strip.&nbsp; We can differentiate this rhythm from the AV blocks because in sinus block, the P wave is missing.&nbsp; In AV block, the P wave is present, but not always conducted.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">To better illustrate what may be happening in this ECG, we have included a laddergram.&nbsp; If you are not familiar with using laddergrams, please refer to the following links.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">ECG Guru, <a title="Guru Laddergrams Blog" href="http://ecgguru.com/ecg/laddergram">Are You New To Laddergrams</a>,&nbsp;&nbsp; Dr. Ken Grauer, <a title="Grauer Making Laddergrams" href="http://ecg-interpretation.blogspot.com/2013/06/ecg-interpretation-review-69-pvc-pjc.html">Making A Laddergram</a>.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">Clinically, we would want to investigate the possible cause of the SA block or atrial bigeminy, and watch for worsening of any block, which could result in a dangerous bradycardia.</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/378/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 Atrial Bigeminy Vs Possible Sino-atrial Exit Block 1/5</option><option value="40">Give Atrial Bigeminy Vs Possible Sino-atrial Exit Block 2/5</option><option value="60">Give Atrial Bigeminy Vs Possible Sino-atrial Exit Block 3/5</option><option value="80" selected="selected">Give Atrial Bigeminy Vs Possible Sino-atrial Exit Block 4/5</option><option value="100">Give Atrial Bigeminy Vs Possible Sino-atrial Exit Block 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 >2</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-oRSIrcGcBSCmW5c-lYGumDmYQVZwr9FcCKVQVjpMIho" /> <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/sino-atrial-exit-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sino-atrial exit block</a></div><div class="field-item odd"><a href="/ecg/sa-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">SA block</a></div><div class="field-item even"><a href="/ecg/sa-block-type-ii" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">SA block Type II</a></div><div class="field-item odd"><a href="/ecg/bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bigeminy</a></div><div class="field-item even"><a href="/ecg/atrial-bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial bigeminy</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%2Finstructors-collection-ecg-week-october-5-2015-sino-atrial-exit-block-0&amp;title=Atrial%20Bigeminy%20Vs%20Possible%20Sino-atrial%20Exit%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> Mon, 05 Oct 2015 23:26:34 +0000 Dawn 670 at https://www.ecgguru.com https://www.ecgguru.com/ecg/instructors-collection-ecg-week-october-5-2015-sino-atrial-exit-block-0#comments Sinus Rhythm With Atrial Bigeminy https://www.ecgguru.com/ecg/sinus-rhythm-atrial-bigeminy <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/sinus-rhythm-atrial-bigeminy"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/MR116.jpg" width="1828" height="1436" 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 ECG is from an 88-year-old man with congestive heart failure. &nbsp;No other clinical information is known. &nbsp;It shows an underlying sinus rhythm with atrial bigeminy - every other beat is a premature atrial contraction. &nbsp;There is very little, if any, difference in the morphology of the sinus P waves and the ectopic P waves, indicating that the ectopic focus is in the vicinity of the sinus node. &nbsp;There is no "compensatory" pause, because PACs penetrate the sinus node, resetting it. &nbsp;So, the underlying sinus rate here is about 72 beats per minute. &nbsp;There are several mechanisms for bigeminy to occur, but ectopic bigeminy is the most common.</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/378/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 Sinus Rhythm With Atrial Bigeminy 1/5</option><option value="40">Give Sinus Rhythm With Atrial Bigeminy 2/5</option><option value="60">Give Sinus Rhythm With Atrial Bigeminy 3/5</option><option value="80">Give Sinus Rhythm With Atrial Bigeminy 4/5</option><option value="100" selected="selected">Give Sinus Rhythm With Atrial Bigeminy 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.5</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--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-Eg2b1Go-1VHxrfwMi7o24aLmExlkybSuKoyO6M9AvyU" /> <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/atrial-bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial bigeminy</a></div><div class="field-item odd"><a href="/ecg/premature-atrial-contraction" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Premature atrial contraction</a></div><div class="field-item even"><a href="/ecg/bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bigeminy</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%2Fsinus-rhythm-atrial-bigeminy&amp;title=Sinus%20Rhythm%20With%20Atrial%20Bigeminy"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 07 Jul 2015 21:56:59 +0000 Dawn 650 at https://www.ecgguru.com https://www.ecgguru.com/ecg/sinus-rhythm-atrial-bigeminy#comments ECG Basics: Sinus Rhythm With Ventricular Bigeminy https://www.ecgguru.com/ecg/ecg-basics-sinus-rhythm-ventricular-bigeminy-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-rhythm-ventricular-bigeminy-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/153%20Sinus%20w%20vent%20bigeminy.jpg" width="1800" height="526" 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 rhythm strip offers two leads taken at the same time, Lead II and Lead V1. &nbsp;The Lead II strip may not look "typical" to a beginning student, because the sinus beats are very small and biphasic. &nbsp;This is due to an axis shift, which cannot be evaluated without more leads.</p><p>One of the best teaching opportunities in this strip is the concept of "underlying rhythm" with ectopy. &nbsp;The underlying rhythm here is sinus. &nbsp;But there are sinus P waves which are hidden, making the sinus rate twice what it appears to be. &nbsp;The P waves are invisible in the Lead II strip, with baseline artifact making them even harder to see. &nbsp;But in V1, we are able to find them at the end of the PVCs' T waves. &nbsp;The sinus rhythm is a bit irregular toward the end of the strip. &nbsp;There are probably many things a more advanced practitioner could say about this strip, but it usually requires more than one or two leads to do a complete evaluation. &nbsp;For your basic student, it is a good example of sinus rhythm with ventricular bigeminy.</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/378/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 ECG Basics: Sinus Rhythm With Ventricular Bigeminy 1/5</option><option value="40">Give ECG Basics: Sinus Rhythm With Ventricular Bigeminy 2/5</option><option value="60">Give ECG Basics: Sinus Rhythm With Ventricular Bigeminy 3/5</option><option value="80" selected="selected">Give ECG Basics: Sinus Rhythm With Ventricular Bigeminy 4/5</option><option value="100">Give ECG Basics: Sinus Rhythm With Ventricular Bigeminy 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--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-QwarhHanQUgpOQPTvIa9FVpjIzYWBTPPRit72L9P9KE" /> <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/ventricular-bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular bigeminy</a></div><div class="field-item odd"><a href="/ecg/bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bigeminy</a></div><div class="field-item even"><a href="/ecg/premature-ventricular-contraction" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Premature ventricular contraction</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_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fecg-basics-sinus-rhythm-ventricular-bigeminy-0&amp;title=ECG%20Basics%3A%20%20Sinus%20Rhythm%20With%20Ventricular%20Bigeminy"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 07 Jul 2015 21:03:46 +0000 Dawn 649 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-sinus-rhythm-ventricular-bigeminy-0#comments Bigeminal Rhythm https://www.ecgguru.com/ecg/bigeminal-rhythm <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/bigeminal-rhythm"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/MR116_0.jpg" width="1828" height="1436" 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>To continue a recent theme, we offer this ECG, which appears on quick glance to be an atrial bigeminy. &nbsp;On closer inspection, we do not see ectopic P' waves in the second conducted beats of each pair. &nbsp;In fact, the P waves look the same in both the first and second beats. However, if you look very closely (we enlarged the screen), you may notice that the second T wave of each pair is slightly larger with a slightly different morphology than the first T wave. &nbsp;If this distortion of the second T waves represents a PAC, the PAC is non-conducted and concealed in the T wave. If that concealed P wave is able to penetrate and depolarize the sinus node, we might expect the sinus node to be reset, and the next P wave and QRS combination is right on time.</p><p>So, what looks like an "atrial bigeminy" might actually be an "atrial trigeminy" - albeit with non-conducted PACs.</p><p>Also notable is the subtle ST elevation in V1, V2, and V3, which should be evaluated with clinical data. Unfortunately, we do not have information about the patient. &nbsp;Also, V2 and V3 do not represent normal or expected R wave progression. &nbsp;The chest leads should have rS patterns, and they should progress from small r waves and deep S waves in V1 with gradually taller R waves and shorter S waves across the chest wall. &nbsp;V6 should be, finally, all upright. &nbsp;We suspect lead reversal between V2 and V3, or misplacement of the electrodes in general. &nbsp;Also, the q waves in those leads seem misplaced, without the usual configuration of pathological Q waves in those leads.</p><p><strong>We would love to hear your opinions about this interesting rhythm.</strong></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/378/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 Bigeminal Rhythm 1/5</option><option value="40">Give Bigeminal Rhythm 2/5</option><option value="60">Give Bigeminal Rhythm 3/5</option><option value="80">Give Bigeminal Rhythm 4/5</option><option value="100" selected="selected">Give Bigeminal Rhythm 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 >2</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-0Jlh_BTytk1zmD_TOAhSewWm7qGAXuShlFs4Ex7n9E8" /> <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/atrial-trigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial trigeminy</a></div><div class="field-item odd"><a href="/ecg/concealed-p-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Concealed P waves</a></div><div class="field-item even"><a href="/ecg/bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bigeminy</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%2Fbigeminal-rhythm&amp;title=Bigeminal%20Rhythm"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 07 Sep 2013 06:09:27 +0000 Dawn 491 at https://www.ecgguru.com https://www.ecgguru.com/ecg/bigeminal-rhythm#comments