ECG Guru - Instructor Resources - Bradycardia https://www.ecgguru.com/ecg/bradycardia en Complete Heart Block With Impending Ventricular Standstill https://www.ecgguru.com/ecg/complete-heart-block-impending-ventricular-standstill <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/complete-heart-block-impending-ventricular-standstill"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB118%20CHB.jpg" width="1800" height="756" 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" style="line-height: normal;">&nbsp;</p><div style="mso-element: comment-list;"><!--[if !supportAnnotations]--><hr class="msocomoff" align="left" size="1" width="33%" /><!--[endif]--></div><p class="MsoNormal" style="line-height: normal;"><strong><span style="color: #00b050;">The Patient</span></strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; This ECG was obtained from a 76-year-old woman who had just lost responsiveness while under care of an EMS crew. This tracing was obtained before a trans-cutaneous pacemaker was applied.</p><div><div><!--[if !supportAnnotations]--><div id="_com_1" class="msocomtxt"><!--[endif]--><!--[if !supportAnnotations]--><a name="_msocom_1"></a><!--[endif]--><p class="MsoNormal" style="line-height: normal;"><strong><span style="color: #00b050;">The ECG</span></strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The most noticeable feature of this ECG is the extremely slow rate. In fact, there are only two QRS complexes visible. The P waves are regular at a rate of about 145 bpm, so the underlying rhythm is sinus tachycardia.&nbsp; NONE of the P waves are conducted, as evidenced by the different “PR intervals” in the two QRS complexes seen.&nbsp; This is complete heart block at it’s most extreme – the QRS complexes represent a very insufficient escape rhythm.&nbsp; A pacemaker is the only immediate treatment for this rhythm. Unfortunately, we don’t know the outcome for this patient.</p><p class="MsoNormal" style="line-height: normal;">It is very difficult to make judgements about the QRS complexes with only two of them, visible in three leads each.&nbsp; The first set show the criteria for left ventricular hypertrophy.&nbsp; The QRS in aVL is 20 mm tall, and anything over 11 mm meets voltage criteria for LVH. &nbsp;In addition, the ST segments have the “strain” pattern, another sign of LVH.&nbsp; The second QRS complexes are not typical of a normal ECG or one with LVH.&nbsp; We cannot vouch for the precordial lead placement.</p><p class="MsoNormal" style="line-height: normal;">There is some disagreement in the literature regarding the naming of the blocks. Some consider “high-grade” to be only second-degree AVB with two or more consecutive non-conducted P waves. Others include third-degree AVB in the “high-grade” category.&nbsp; It can come down to just semantics – the RATE and how the patient responds to the rate is the primary consideration.&nbsp; Classification as to the origin of the block is helpful when determining the best long-term treatment decisions.</p><p class="MsoNormal" style="line-height: normal;">This is a good ECG for teaching the concept of AV dissociation, and how dangerous third-degree AV blocks and high-grade second-degree AV blocks can be.&nbsp;&nbsp;</p><!--[if !supportAnnotations]--></div><!--[endif]--></div></div><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/39/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 Complete Heart Block With Impending Ventricular Standstill 1/5</option><option value="40">Give Complete Heart Block With Impending Ventricular Standstill 2/5</option><option value="60">Give Complete Heart Block With Impending Ventricular Standstill 3/5</option><option value="80" selected="selected">Give Complete Heart Block With Impending Ventricular Standstill 4/5</option><option value="100">Give Complete Heart Block With Impending Ventricular Standstill 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 >6</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-KBfm00iCluOedP1kUyqd34xqGYyYSc3Bu5N-onYe7xQ" /> <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/complete-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete AV block</a></div><div class="field-item odd"><a href="/ecg/third-degree-av-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Third-degree AV block</a></div><div class="field-item even"><a href="/ecg/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</a></div><div class="field-item odd"><a href="/ecg/impending-ventricular-standstill" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Impending ventricular standstill</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%2Fcomplete-heart-block-impending-ventricular-standstill&amp;title=Complete%20Heart%20Block%20With%20Impending%20Ventricular%20Standstill"><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> Wed, 18 Dec 2019 00:02:15 +0000 Dawn 779 at https://www.ecgguru.com https://www.ecgguru.com/ecg/complete-heart-block-impending-ventricular-standstill#comments Catastrophic Event With Bradycardia https://www.ecgguru.com/ecg/catastrophic-event-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/catastrophic-event-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AWMI%20127%20from%20Lt%20V%20Levin%201613.jpg" width="1800" height="609" alt="" /></a></div><div class="field-item odd"><a href="/ecg/catastrophic-event-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AWMI%20127%20from%20Lt%20V%20Levin%201620.jpg" width="1800" height="620" 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" style="margin-bottom: .0001pt; line-height: normal;"><strong style="mso-bidi-font-weight: normal;"><span style="font-family: 'Arial',sans-serif; color: #00b050;">The Patient:</span></strong><span style="font-family: 'Arial',sans-serif; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 10.0pt; font-family: 'Arial',sans-serif; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;</span></span><span style="font-size: 10.0pt; font-family: 'Arial',sans-serif;">Paramedics were summoned to the home of a 74-year-old woman who had a complaint of shortness of breath.<span style="mso-spacerun: yes;">&nbsp; </span>She was found sitting, alert and oriented, with labored respirations at 30/min. She stated that the shortness of breath came on suddenly. She denied any cardiac or pulmonary medical history, and said she took no medications. The patient was ambulatory.<span style="mso-spacerun: yes;">&nbsp; </span>Her skin was cool and moist.<span style="mso-spacerun: yes;">&nbsp; </span>Her SpO2 on room air was 85%, improving to 90% on oxygen via 15 lpm non-rebreather mask.<span style="mso-spacerun: yes;">&nbsp; </span>Her lungs sounded clear. </span></p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><span style="font-size: 8.0pt; font-family: 'Arial',sans-serif;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><span style="font-size: 10.0pt; font-family: 'Arial',sans-serif;">When the patient was moved to the transport vehicle, she suddenly became nonverbal, with a leftward gaze. Her pupils were noted to be unequal and non-reactive (we do not know which was larger).<span style="mso-spacerun: yes;">&nbsp; </span>Her BP was 67/43.</span></p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><span style="font-size: 8.0pt; font-family: 'Arial',sans-serif;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><span style="font-size: 10.0pt; font-family: 'Arial',sans-serif;">During transport, her heart rate declined into the 20’s and became apneic and pulseless.<span style="mso-spacerun: yes;">&nbsp; </span>Recorded BP was 46/25. CPR was done until and after arrival at the hospital, where efforts to resuscitate were halted after some time.</span></p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><span style="font-size: 10.0pt; font-family: 'Arial',sans-serif;">&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><strong style="mso-bidi-font-weight: normal;"><span style="font-family: 'Arial',sans-serif; color: #00b050;">ECG Number 1:<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span></strong><span style="font-size: 10.0pt; font-family: 'Arial',sans-serif;">The first ECG, shown here, was taken approximately 8 minutes after arrival of EMS.<span style="mso-spacerun: yes;">&nbsp; </span>There is significant artifact, making it difficult to comment with certainty on the QRS width, P waves, and J points.<span style="mso-spacerun: yes;">&nbsp; </span>P waves are best viewed in the right-sided chest leads, V1 through V3. The QRS morphology appears normal and the intervals are within normal ranges.</span></p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><span style="font-size: 10.0pt; font-family: 'Arial',sans-serif;">&nbsp;</span><span style="font-size: 10pt; font-family: Arial, sans-serif;">The ST segments appear to&nbsp; be elevated in V2 through V5, and the machine’s interpretation confirms this (although the artifact can make measurement difficult for the machine also).&nbsp; In addition to J point elevation, the SHAPE of the ST segments in the precordial leads is abnormal –straightening and losing the “smile” shape that is normal. There is some mild ST depression in Lead III.&nbsp;</span><span style="font-family: Arial, sans-serif; font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-family: 'Arial',sans-serif; color: #00b050;">ECG Number 2:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="font-size: 10.0pt; line-height: 107%; font-family: 'Arial',sans-serif;">The second ECG, performed about nine minutes later, shows what happened when the patient’s condition suddenly declined.<span style="mso-spacerun: yes;">&nbsp; </span>Her heart rate declined to about 20 bpm, and she<span style="mso-spacerun: yes;">&nbsp; </span>was pulseless.<span style="mso-spacerun: yes;">&nbsp; </span>Keeping in mind that the three channels of this 12-lead ECG are run simultaneously.<span style="mso-spacerun: yes;">&nbsp; </span>So, Leads I, II, and III are recorded together, and the QRS morphology matches that of ECG No. 1.<span style="mso-spacerun: yes;">&nbsp; </span>Then, when aVR, aVL, and aVF are recorded, the QRS morphology changes and becomes wider at around .12 seconds (120 ms) or more.<span style="mso-spacerun: yes;">&nbsp; </span>This represents an “escape” rhythm. Even though the ECG machine records an axis for the P wave, and a PR interval, P waves appear very flat in the first 3 seconds of the ECG, and non-existent in the rest of the leads.</span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 12.0pt; line-height: 107%; font-family: 'Arial',sans-serif; color: #00b050;">Assessment:<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span></strong><span style="font-size: 10.0pt; line-height: 107%; font-family: 'Arial',sans-serif;">It is obvious that an acute catastrophic event happened to this patient.<span style="mso-spacerun: yes;">&nbsp; </span>Because she died before definitive tests could be performed, we will never know what it was.<span style="mso-spacerun: yes;">&nbsp; </span>The ECG signs of ST elevation and failure of the primary pacemaker certainly fall within the realm of acute myocardial infarction, but the only symptom initially was shortness of breath, which would be a possible, but atypical, presentation.<span style="mso-spacerun: yes;">&nbsp; </span>She also exhibited some clinical signs of many other life-threatening illnesses, such as stroke or pulmonary embolism, but without “typical” ECG changes. </span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%; font-family: 'Arial',sans-serif;">In retrospect, we are left wondering if an M.I. caused loss of perfusion, which led to the other symptoms, or if another condition lowered perfusion, causing STEMI signs on the ECG.<span style="mso-spacerun: yes;">&nbsp; </span>The common denominator here is <em style="mso-bidi-font-style: normal;">perfusion, </em>and our goal should be to restore perfusion in order to gain time to find and treat the culprit disorder. Depending upon the setting we operate in, we might use I.V. fluids, temporary transvenous or transcutaneous pacing, mechanical ventilation, drugs, or chest compressions to try to maintain perfusion to the brain and coronary arteries.<span style="mso-spacerun: yes;">&nbsp; </span>Of course, some catastrophic medical events are just that – catastrophic – and, sadly, our efforts fail.</span></p><p>Our thanks to Lt. Vincent Levin for donating these ECGs.</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/39/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 Catastrophic Event With Bradycardia 1/5</option><option value="40">Give Catastrophic Event With Bradycardia 2/5</option><option value="60">Give Catastrophic Event With Bradycardia 3/5</option><option value="80">Give Catastrophic Event With Bradycardia 4/5</option><option value="100" selected="selected">Give Catastrophic Event With Bradycardia 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--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-CSjQ-ZRlnvVMI4h-uGwnDzzp5fTjwFQJknBaY7Dk9fQ" /> <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/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/anterior-wall-mi-5" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior wall M.I.</a></div><div 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/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</a></div><div class="field-item even"><a href="/ecg/pulseless-electrical-activity" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pulseless electrical activity</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%2Fcatastrophic-event-bradycardia&amp;title=Catastrophic%20Event%20With%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, 22 Apr 2018 20:46:09 +0000 Dawn 756 at https://www.ecgguru.com https://www.ecgguru.com/ecg/catastrophic-event-bradycardia#comments An Irregular Bradycardia https://www.ecgguru.com/ecg/irregular-bradycardia <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/irregular-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20Lead%209%2029%20am.jpg" width="1800" height="1078" alt="" /></a></div><div class="field-item odd"><a href="/ecg/irregular-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12-Lead%2010%2042%20am.jpg" width="2008" height="1166" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal">Thank you to Alikuni Kllany from Toronto for donating these ECGs.&nbsp; They are from a 59-year-old man who has a history of hypertension and depression.&nbsp; Last year, he was on atenolol when he experienced a brief syncopal episode and bradycardia. He was taken off atenolol and started on amlodipine 5 mg.&nbsp; He also takes ramipril 10 mg, atorvastatin 40 mg, and tamsulosin .4 mg.&nbsp; He continues to have bradycardia and dizziness.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The first ECG shows grouped beating, with repetitive groups of two and three complexes.&nbsp; The P waves are very small, and hard to evaluate.&nbsp; The best place to see them is in the Lead II rhythm strip at the bottom.&nbsp; The rhythm strip is not run concurrently with the 12-Lead, making it even more difficult to evaluate P wave morphology.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The beats that begin the groups also END a pause.&nbsp; These are junctional escape beats.&nbsp; After the junctional escape beats, the PR intervals vary.&nbsp; This can be explained by <a href="http://ecgguru.com/expert-review/ask-expert-6">RP / PR reciprocity</a>, first described by Mobitz.&nbsp; He demonstrated that the RP interval can affect the next PR interval. Longer RP intervals (slower rate) cause PR shortening.&nbsp; Shorter RP intervals equal longer PR intervals.&nbsp; The P waves are so small, it is difficult to determine whether there is a P wave in the last T wave of each group, which would indicate non-conducted PACs.&nbsp; So, we are left with a sinus pause or sinus exit block (suggested by the timing of the first six beats.&nbsp; We have used red arrows to suggest where the sinus node probably fired.&nbsp; P waves indicate conduction, of course.&nbsp; Lack of P waves, the impulse failed to exit the sinus node.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">There are many mechanisms by which grouped beating can occur.&nbsp; Second-degree AVB, Type I (Wenckebach) comes to mind first.&nbsp; That rhythm in it’s pure form would have a regular sinus rhythm underlying it. &nbsp;&nbsp;Escape-capture bigeminy often occurs with slow rates and junctional escapes, but does not by itself cause “trigeminy”.&nbsp; Sick sinus syndrome can cause all types of chaos in the rhythm.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The second tracing shows a junctional escape rhythm with no obvious P waves (unsure because the P waves are small, and the 12-Lead is not concurrent with the rhythm strip at the bottom.)&nbsp; It is interesting that the rhythm strip shows four consecutive sinus beats at just under 60 bpm, and with P waves that look different from the P waves on the first ECG. &nbsp;This rate is similar, but not identical to, the sinus rate seen in the first ECG.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The bottom line for the clinician is that this patient, because he is symptomatic, requires a thorough workup.&nbsp; If the cause of the arrhythmias proves to be cardiac in origin, a pacemaker may be required.</p><p class="MsoNormal"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></p><p>&nbsp;</p><p class="MsoNormal">We welcome any and all discussions regarding this ECG, realizing that P waves are very difficult to evaluate, and that they are probably multi-focal.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/39/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 An Irregular Bradycardia 1/5</option><option value="40">Give An Irregular Bradycardia 2/5</option><option value="60">Give An Irregular Bradycardia 3/5</option><option value="80">Give An Irregular Bradycardia 4/5</option><option value="100" selected="selected">Give An Irregular Bradycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.3</span></span> <span class="total-votes">(<span >7</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-ab-c2di5ysDzTbrQJJSwYxIGy7ZkYrolEEr9tkwr_Hs" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/junctional-escape" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional escape</a></div><div class="field-item odd"><a href="/ecg/escape-capture-bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Escape-capture bigeminy</a></div><div class="field-item even"><a href="/ecg/r-p-p-r-reciprocity" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">R-P / P-R reciprocity</a></div><div class="field-item odd"><a href="/ecg/sinus-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus block</a></div><div class="field-item even"><a href="/ecg/sinus-pause" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus pause</a></div><div class="field-item odd"><a href="/ecg/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Firregular-bradycardia&amp;title=%20%20An%20Irregular%20Bradycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 31 Mar 2016 21:05:12 +0000 Dawn 693 at https://www.ecgguru.com https://www.ecgguru.com/ecg/irregular-bradycardia#comments ECG Basics: Junctional Rhythm https://www.ecgguru.com/ecg/ecg-basics-junctional-rhythm-1 <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-junctional-rhythm-1"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/150%20Junctional%20Rhythm%20strp.jpg" width="1800" height="190" 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 an example of a junctional rhythm that is slower than what is considered "intrinsic rate" for the junction. &nbsp;The rate is around 30 bpm. &nbsp;We know this is a "supraventricular" rhythm because of the narrow QRS. &nbsp;Junctional beats travel to the ventricles via the bundle branches, which provides very fast conduction, resulting in a narrow QRS complex. &nbsp;The P waves can be seen at the end of each QRS. &nbsp;They are upside-down in this Lead II rhythm strip, indicating <strong>retrograde</strong> conduction from the junctional pacemaker to the atria.</p><p>Clinically, the important thing when we encounter such a slow rate is to evaluate the patient's response to the rate. &nbsp;If the patient is hypoperfused (pale, decreased level of consciousness, low BP), we need to act to increase the rate, regardless of the cause of the 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/39/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 ECG Basics: Junctional Rhythm 1/5</option><option value="40">Give ECG Basics: Junctional Rhythm 2/5</option><option value="60" selected="selected">Give ECG Basics: Junctional Rhythm 3/5</option><option value="80">Give ECG Basics: Junctional Rhythm 4/5</option><option value="100">Give ECG Basics: Junctional Rhythm 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >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--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-65lgpOZRBlnKHC8cm-9ipoOc64LKyYXPrfaMbIcmArs" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/junctional" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional</a></div><div class="field-item odd"><a href="/ecg/retrograde-conduction" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Retrograde conduction</a></div><div class="field-item even"><a href="/ecg/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">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/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</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></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%2Fecg-basics-junctional-rhythm-1&amp;title=ECG%20Basics%3A%20%20Junctional%20Rhythm"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 19 Mar 2015 18:40:37 +0000 Dawn 628 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-junctional-rhythm-1#comments Acute Inferior Wall M.I. https://www.ecgguru.com/ecg/acute-inferior-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/acute-inferior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/66-M2%20IWMI%20%20Testerman.jpg" width="1800" height="776" 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="color: #222222; font-family: Arial, sans-serif; line-height: 15pt;">Another great ECG donated by Paramedic Eric Testerman. &nbsp;This ECG is from a 66 year old man who was complaining of feeling dizzy, weak, and of having "minor" chest pain. He was extremely pale/ashen, had moderate cyanosis, and was very clammy and diaphoretic. &nbsp;His initial heart rate was about 20 bpm. &nbsp;His initial BP was 131/113 then, just before arrival at the hospital was 127/85. His HR increased to about 50 bpm (not shown). He was given 400 ml I.V. fluid, 324 gr of aspirin, and oxygen. &nbsp;Transcutaneous defibrillator/pacemaker pads were applied.</span><span style="font-family: Arial, sans-serif; line-height: 15pt;">&nbsp;</span></p><p class="MsoNormal" style="line-height: 15pt;"><span style="font-family: Arial, sans-serif; color: #222222; border: 1pt none windowtext; padding: 0in;">At the hospital, he was successfully treated with angioplasty for a 100% occlusion of the right coronary artery. The time from beginning of treatment to reperfusion of the artery was 47 minutes, which is very good!</span><span style="font-family: Arial, sans-serif; line-height: 15pt;">&nbsp;</span></p><p class="MsoNormal" style="line-height: 15pt;"><span style="font-family: Arial, sans-serif; color: #222222; border: 1pt none windowtext; padding: 0in;">This is a "classic" inferior wall M.I., with ST elevation in leads II, III, and aVF. There are reciprocal ST depressions in I and aVL. &nbsp;There are also ST depressions in V1 through V5. &nbsp;This is generally considered to represent reciprocal ST changes in the posterior and lateral walls.</span><span style="color: #222222; font-family: Arial, sans-serif; line-height: 15pt;">There is a quite severe bradycardia, and the patient's skin showed signs of poor perfusion. Amazingly, the patient's BP stayed adequate during transport. &nbsp;Bradycardia is common in inferior wall M.I. due to ischemic effects on the SA node and vagus nerve (sinus bradycardia) and the AV node (heart block). &nbsp;In this case, the rhythm is sinus bradycardia. &nbsp;The heart rate is in the 20's, and the PR interval is around .20 - .22 seconds.</span><span style="font-family: Arial, sans-serif; line-height: 15pt;">&nbsp;</span></p><p class="MsoNormal" style="line-height: 15pt;"><span style="font-family: Arial, sans-serif; color: #222222; border: 1pt none windowtext; padding: 0in;">This patient's unstable condition and close proximity to the hospital prevented the EMS crew from getting a second ECG, but when there is time, a repeat ECG with a V4R lead can be helpful in deciding how much I.V. fluid is safe to give. &nbsp;This patient's heart rate improved spontaneously during transport, but had it not, the transcutaneous pacemaker could have been used. &nbsp;In some protocols, a trial of Atropine is advised. &nbsp;In others, treatment goes straight to the pacemaker or to I.V. epinephrine. &nbsp;During the angioplasty, a transvenous pacemaker is often inserted into the right ventricle to support the patient's rate if necessary.&nbsp;</span><span style="font-family: Arial, sans-serif; line-height: 15pt;">&nbsp;</span></p><p class="MsoNormal" style="line-height: 15pt;"><span style="font-family: Arial, sans-serif; color: #222222; border: 1pt none windowtext; padding: 0in;">This patient was fortunate to be in an area with advanced paramedics and an interventional cath lab close by. &nbsp;It is notable that he never developed pathological Q waves, and hopefully had an uneventful recovery.&nbsp;&nbsp;</span></p><p class="MsoNormal" style="margin: 12pt 0in; line-height: 15pt;"><span style="font-family: Arial, sans-serif;">&nbsp;</span></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/39/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 Acute Inferior Wall M.I. 1/5</option><option value="40">Give Acute Inferior Wall M.I. 2/5</option><option value="60">Give Acute Inferior Wall M.I. 3/5</option><option value="80">Give Acute Inferior Wall M.I. 4/5</option><option value="100" selected="selected">Give Acute 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 >4.5</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--5" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-yhn_1qz1QqzBWKXQ6vBJv2YAlPuHVYsde98l-dTXyVk" /> <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/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</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/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</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%2Facute-inferior-wall-mi&amp;title=Acute%20Inferior%20Wall%20M.I.%20"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 15 Apr 2014 06:08:12 +0000 Dawn 567 at https://www.ecgguru.com https://www.ecgguru.com/ecg/acute-inferior-wall-mi#comments ECG Basics: Junctional Rhythm https://www.ecgguru.com/ecg/ecg-basics-junctional-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/ecg-basics-junctional-rhythm"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/118%20Junct%20rhythm.jpg" width="1800" height="337" 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 illustrates a junctional escape rhythm. &nbsp;The sinus rhythm has slowed or stopped, and the junctional tissue has taken over as the pacemaker of the heart. &nbsp;The "junction" is loosely defined as the area between the AV node and the Bundle of His. &nbsp;The intrinsic rate of the pacemaking tissue in this area is 40 - 60 beats per minute. &nbsp;This slow rate is usually overridden by the sinus node, and the junction is not allowed to express itself as a pacemaker. &nbsp;Should the sinus node fail or fall below the junctional rate, the junction "escapes" and takes control of the heart. &nbsp;The QRS complex in junctional rhythm will normally be <strong>narrow</strong>, because the impulse follows the bundle branches down through the ventricles in a normal fashion, resulting in quick and normal ventricular depolarization.&nbsp;<span style="line-height: 1.538em;">&nbsp;If the QRS complex is wide in a junctional rhythm, there is another, separate cause, such as bundle branch block.</span></p><p><span style="line-height: 1.538em;">&nbsp;If the junctional impulse is able to penetrate the AV node and depolarlize the atria, the P wave will be deflected downward in Leads II, III, and aVF, as the impulse is travelling in a retrograde direction (backward). &nbsp;The P wave could end up slightly before the QRS, during the QRS, or after the QRS. In this strip, the P waves are seen after the QRS complexes.</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/39/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 ECG Basics: Junctional Rhythm 1/5</option><option value="40">Give ECG Basics: Junctional Rhythm 2/5</option><option value="60">Give ECG Basics: Junctional Rhythm 3/5</option><option value="80" selected="selected">Give ECG Basics: Junctional Rhythm 4/5</option><option value="100">Give ECG Basics: Junctional Rhythm 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 >4</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-D_xcEZOR-CxJrVnCRIwhcdC6CpdlsJ_-tOxQ5Cz6iUI" /> <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/retrograde-p-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Retrograde P waves</a></div><div class="field-item odd"><a href="/ecg/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</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/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/junctional" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional</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%2Fecg-basics-junctional-rhythm&amp;title=ECG%20Basics%3A%20%20Junctional%20Rhythm"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Mon, 21 Oct 2013 04:29:48 +0000 Dawn 505 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-junctional-rhythm#comments ECG Challenge From Dr. Ahmed - Patient With Hyperkalemia https://www.ecgguru.com/ecg/ecg-challenge-dr-ahmed-patient-hyperkalemia <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-challenge-dr-ahmed-patient-hyperkalemia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AFib%20from%20Dr.%20Ahmed.jpg" width="1800" height="1279" 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 was kindly donated to the ECG Guru website by Dr. Ahmed for open discussion among our members. &nbsp;The patient was a 70+ year-old man who presented with a complaint of dizziness. &nbsp;His serum potassium level was found to be 6.5 (normal is 3.5 - 5.0). &nbsp;Upon correction of his K levels, his rhythm was atrial fibrillation at 130 / min.</p><p>WHAT DO YOU THINK ABOUT THIS INITIAL ECG? &nbsp;What is causing the slow rate? Is there atrial activity? &nbsp;Do you see QRS morphology changes? &nbsp;What about the anterior ST and T wave changes?&nbsp;</p><p>We look forward to hearing from our members! &nbsp;And thanks to Dr. Ahmed for donating this interesting ECG.</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/39/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 ECG Challenge From Dr. Ahmed - Patient With Hyperkalemia 1/5</option><option value="40">Give ECG Challenge From Dr. Ahmed - Patient With Hyperkalemia 2/5</option><option value="60">Give ECG Challenge From Dr. Ahmed - Patient With Hyperkalemia 3/5</option><option value="80">Give ECG Challenge From Dr. Ahmed - Patient With Hyperkalemia 4/5</option><option value="100" selected="selected">Give ECG Challenge From Dr. Ahmed - Patient With Hyperkalemia 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-_R0Id_kMQuOsAaiwMKVA6ghbbB_diuNG9gvI9F1A3r8" /> <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/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</a></div><div class="field-item odd"><a href="/ecg/fib" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">A Fib</a></div><div class="field-item even"><a href="/ecg/hyperkalemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperkalemia</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%2Fecg-challenge-dr-ahmed-patient-hyperkalemia&amp;title=ECG%20Challenge%20From%20Dr.%20Ahmed%20-%20Patient%20With%20Hyperkalemia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 26 Jul 2013 22:03:56 +0000 Dawn 472 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-challenge-dr-ahmed-patient-hyperkalemia#comments Right Bundle Branch Block With Atypical QRS in V1 and LAFB or Ventricular Rhythm??? https://www.ecgguru.com/ecg/right-bundle-branch-block-atypical-qrs-v1-and-lafb-or-ventricular-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/right-bundle-branch-block-atypical-qrs-v1-and-lafb-or-ventricular-rhythm"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/RBLAH102.jpg" width="1709" height="1247" 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 quite an interesting ECG, and the ECG Guru would love to hear what you think about it.&nbsp; What we do know is that it is a wide-complex bradycardia in a patient for whom we have no clinical data, except that she is a 51 year old female.&nbsp; The rhythm is probably junctional, as no P waves are seen and the rhythm is regular.&nbsp; The rate of 63 per minute would be consistent with that. Interestingly, no disassociated sinus P waves are seen.&nbsp; All slow wide-complex rhythms should be evaluated for idioventricular origin, or AIVR.&nbsp; The QRS in V1 shows an atypical right bundle branch block pattern.&nbsp; We usually look for rSR', or "bunny ears", &nbsp;but&nbsp; this ECG shows an upright R wave with a smaller, slurred r wave before it.&nbsp; What makes this look like RBBB is the prominent wide little S wave in V6 and in Lead I.&nbsp; We question the R wave progression, too.&nbsp; Do you think it is possible that the electrodes for V2 and V3 are switched?&nbsp; The axis is leftward, causing Lead II to be nearly biphasic - it represents a synthesis of what is seen in Leads I and III.&nbsp; This is enough left axis shift to diagnose a left anterior fascicular block (with RBBB = bifascicular block).&nbsp;</p><p>This is a great ECG, and we can't wait to hear from all you ECG Gurus out there.&nbsp;Maybe we will need to adjust our diagnosis after we hear from you.</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/39/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 Right Bundle Branch Block With Atypical QRS in V1 and LAFB or Ventricular Rhythm??? 1/5</option><option value="40">Give Right Bundle Branch Block With Atypical QRS in V1 and LAFB or Ventricular Rhythm??? 2/5</option><option value="60">Give Right Bundle Branch Block With Atypical QRS in V1 and LAFB or Ventricular Rhythm??? 3/5</option><option value="80" selected="selected">Give Right Bundle Branch Block With Atypical QRS in V1 and LAFB or Ventricular Rhythm??? 4/5</option><option value="100">Give Right Bundle Branch Block With Atypical QRS in V1 and LAFB or Ventricular Rhythm??? 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--8" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-NUYLYI2RCrvVpPzbGzSXodsJQc6ei1sgOWK9BRya_gg" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item odd"><a href="/ecg/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</a></div><div class="field-item even"><a href="/ecg/lafb" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">LAFB</a></div><div class="field-item odd"><a href="/ecg/fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Fascicular block</a></div><div class="field-item even"><a href="/ecg/hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hemiblock</a></div><div class="field-item odd"><a href="/ecg/fascicular-aivr" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Fascicular AIVR</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%2Fright-bundle-branch-block-atypical-qrs-v1-and-lafb-or-ventricular-rhythm&amp;title=%20Right%20Bundle%20Branch%20Block%20With%20Atypical%20QRS%20in%20V1%20and%20LAFB%20or%20Ventricular%20Rhythm%3F%3F%3F"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 28 Mar 2013 01:28:19 +0000 Dawn 427 at https://www.ecgguru.com https://www.ecgguru.com/ecg/right-bundle-branch-block-atypical-qrs-v1-and-lafb-or-ventricular-rhythm#comments Wide Complex Bradycardia in Digitalis Toxic Patient https://www.ecgguru.com/ecg/wide-complex-bradycardia-digitalis-toxic-patient <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/wide-complex-bradycardia-digitalis-toxic-patient"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/DE100.jpg" width="1400" height="541" 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 a female patient who presented with weakness. Her labs revealed digitalis toxicity and hyperkalemia. Actual lab values not available. With digitalis toxicity, hypokalemia and hyperkalemia are possible. In severe hyperkalemia, the "tall peaked T waves" can become much shorter, as the QRS and T waves widen. The p waves disappear, and soon the ECG resembles a "sine" wave. This is a very serious emergency!</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/39/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" selected="selected">Give Wide Complex Bradycardia in Digitalis Toxic Patient 1/5</option><option value="40">Give Wide Complex Bradycardia in Digitalis Toxic Patient 2/5</option><option value="60">Give Wide Complex Bradycardia in Digitalis Toxic Patient 3/5</option><option value="80">Give Wide Complex Bradycardia in Digitalis Toxic Patient 4/5</option><option value="100">Give Wide Complex Bradycardia in Digitalis Toxic Patient 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >1</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--9" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-wEP2DQp8KHSy-RSW2FiKHtVtiuBXFc7B_347eU_AUeU" /> <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/wide-qrs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide QRS</a></div><div class="field-item odd"><a href="/ecg/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</a></div><div class="field-item even"><a href="/ecg/digitalis-toxicity" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Digitalis Toxicity</a></div><div class="field-item odd"><a href="/ecg/hyperkalemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperkalemia</a></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%2Fecg%2Fwide-complex-bradycardia-digitalis-toxic-patient&amp;title=Wide%20Complex%20Bradycardia%20in%20Digitalis%20Toxic%20Patient"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Mon, 12 Dec 2011 20:54:23 +0000 Dawn 124 at https://www.ecgguru.com https://www.ecgguru.com/ecg/wide-complex-bradycardia-digitalis-toxic-patient#comments