ECG Guru - Instructor Resources - Wenckebach https://www.ecgguru.com/ecg/wenckebach en SECOND DEGREE AVB TYPE I (WENCKEBACH) https://www.ecgguru.com/blog/second-degree-avb-type-i-wenckebach <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/second-degree-avb-type-i-wenckebach"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/guru%201.jpg" width="3205" height="2045" 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>We see the EKG of an 81-year-old patient with a pacemaker; the PM was briefly deactivated to assess the patient's intrinsic heart rhythm. At the beginning of the EKG, there is already a prolonged AV conduction time, which progressively lengthens from beat to beat. The last conducted P-wave has a PR interval of nearly 800 ms (!). The next P-wave is blocked, but the subsequent displayed P-waves are conducted again, with the PR interval increasing from beat to beat. This indicates a classic second degree AVB Type Mobitz I (Wenckebach). The only unusual aspect is the very long AV conduction time.</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/589/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" selected="selected">Give SECOND DEGREE AVB TYPE I (WENCKEBACH) 1/5</option><option value="40">Give SECOND DEGREE AVB TYPE I (WENCKEBACH) 2/5</option><option value="60">Give SECOND DEGREE AVB TYPE I (WENCKEBACH) 3/5</option><option value="80">Give SECOND DEGREE AVB TYPE I (WENCKEBACH) 4/5</option><option value="100">Give SECOND DEGREE AVB TYPE I (WENCKEBACH) 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" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-hoNapqdhQNxPngrjMx2H6M-duC5wpCr01Bad0lMsmJ8" /> <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%2Fsecond-degree-avb-type-i-wenckebach&amp;title=SECOND%20DEGREE%20AVB%20TYPE%20I%20%28WENCKEBACH%29"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Sat, 05 Aug 2023 09:27:18 +0000 Dr A Röschl 863 at https://www.ecgguru.com https://www.ecgguru.com/blog/second-degree-avb-type-i-wenckebach#comments Why is this not second degree AVB Type II and no high grade AVB https://www.ecgguru.com/blog/why-not-second-degree-avb-type-ii-and-no-high-grade-avb <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/why-not-second-degree-avb-type-ii-and-no-high-grade-avb"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/1.jpg" width="3126" height="1785" alt="" /></a></div><div class="field-item odd"><a href="/blog/why-not-second-degree-avb-type-ii-and-no-high-grade-avb"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/2.jpg" width="3139" height="1793" alt="" /></a></div><div class="field-item even"><a href="/blog/why-not-second-degree-avb-type-ii-and-no-high-grade-avb"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/3_0.jpg" width="3143" height="1780" 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><strong>(Image 1)</strong> Why is there no second-degree AVB&nbsp; Mobitz type II and no high-grade AV block? To the first question: Basically, second-degree AV block Mobitz type II is rare. The two ECG patterns that can easily be confused with Type II Mobitz block are: blocked/non-conducted PACs and second-degree AVB Mobitz type I (Wenckebach). (<strong>Image 2)</strong> You have to compare the PR duration before the pause and after it. With the naked eye, the difference is often difficult to recognize, a pair of calipers does a good job here. In this ECG, the PR duration after the failed QRS is significantly shorter than that before the pause, so there is a Wenckebach block here. Due to the time of day (5:30 am), it can be assumed that the patient was still asleep. Under influence of the vagal nerve, AVB Wenckebach is common. In most cases there is no need for any treatment. <strong>(Image 3 )</strong> 1, 2 and 3 are transmitted P waves (in sinus rhythm) with a significantly prolonged PR interval (first-degree AVB). 4 represents the next P (at the end of the QRS of the PVC) that comes from the sinus node. Due to the refractority period of the AV node or the bundle branches, this sinus beat can not be conducted to the ventricles. At 5, a high-frequency atrial tachycardia begins with a rate of around 170 bpm. 5 to 7 are not conducted.&nbsp; 8 is conducted, 9 and 10 not conducted, 11 conducted, 12 and 13 not conducted, 14 conducted. Then the tachycardia ends and 15 is the first P wave that comes from the sinus node. Thus, there is no high-grade AV block in the classic sense, because we are dealing here with atrial tachycardia and the AV node is allowed to block high-frequency PAC runs. This is not pathological, but is considered to be a "physiological block".</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/589/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 Why is this not second degree AVB Type II and no high grade AVB 1/5</option><option value="40">Give Why is this not second degree AVB Type II and no high grade AVB 2/5</option><option value="60">Give Why is this not second degree AVB Type II and no high grade AVB 3/5</option><option value="80">Give Why is this not second degree AVB Type II and no high grade AVB 4/5</option><option value="100" selected="selected">Give Why is this not second degree AVB Type II and no high grade AVB 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--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-Rbk11Ui-6sJqVZOVQgiPaPveDwPdpLtkgtVy0w6HgW0" /> <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_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fblog%2Fwhy-not-second-degree-avb-type-ii-and-no-high-grade-avb&amp;title=Why%20is%20this%20not%20second%20degree%20AVB%20Type%20II%20and%20no%20high%20grade%20AVB"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 03 Jun 2023 10:32:11 +0000 Dr A Röschl 847 at https://www.ecgguru.com https://www.ecgguru.com/blog/why-not-second-degree-avb-type-ii-and-no-high-grade-avb#comments ECG Basics: Second-degree AV Block, Type I https://www.ecgguru.com/ecg/ecg-basics-second-degree-av-block-type-i <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-second-degree-av-block-type-i"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Wenckebach%20w%20long%20cycles.jpg" width="2895" height="479" 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 two-lead rhythm strip shows a normal sinus rhythm at about 63 bpm.&nbsp; The P waves are regular. After the sixth P-QRS, there is a non-conducted P wave.&nbsp; The normal rhythm then resumes.&nbsp; The two most common reasons for a non-conducted P wave in the midst of a normal sinus rhythm are 1) non-conducted PAC, and 2) Wenckebach conduction. The first is easy to rule out.&nbsp; The non-conducted P wave is not premature, so it is not a PAC.&nbsp; The second one is a little harder when we only have a short strip to look at.&nbsp; We are conditioned to look for progressively-prolonging PR intervals until a QRS is "dropped".&nbsp; In this case, the progression is in very tiny increments that are hard to see unless you zoom in and measure.&nbsp; But they ARE progressively prolonging.&nbsp; An easy hack:&nbsp; measure the last PRI before the dropped beat and the first one after the pause.&nbsp; You will see that the cycle ends on a longer PRI (about .28 seconds) and the new cycle starts up with a PR interval of about .20 seconds.&nbsp; Fortunately, this conduction ratio will have very little effect on the patient's heart 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/589/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: Second-degree AV Block, Type I 1/5</option><option value="40">Give ECG Basics: Second-degree AV Block, Type I 2/5</option><option value="60">Give ECG Basics: Second-degree AV Block, Type I 3/5</option><option value="80" selected="selected">Give ECG Basics: Second-degree AV Block, Type I 4/5</option><option value="100">Give ECG Basics: Second-degree AV Block, Type I 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 >45</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-Z-CR-fAhjhIhofk9eH_f2s87mn6Ezsdgru5Cw0OQs54" /> <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/basic-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Basic ECG</a></div><div class="field-item odd"><a href="/ecg/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item even"><a href="/ecg/second-degree-av-block-type-i" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Second-degree AV block Type I</a></div><div class="field-item odd"><a href="/ecg/wenckebach" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wenckebach</a></div><div class="field-item even"><a href="/ecg/av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AV Block</a></div><div class="field-item odd"><a href="/ecg/mobitz-i-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Mobitz I 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%2Fecg-basics-second-degree-av-block-type-i&amp;title=ECG%20Basics%3A%20%20Second-degree%20AV%20Block%2C%20Type%20I"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 02 Feb 2022 19:43:10 +0000 Dawn 812 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-second-degree-av-block-type-i#comments ECG Basics: Second-degree AV Block With Characteristics of Type I and Type II https://www.ecgguru.com/ecg/ecg-basics-second-degree-av-block-characteristics-type-i-and-type-ii <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-second-degree-av-block-characteristics-type-i-and-type-ii"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/2nd%20deg%20T%20II%20with%20Wenchebach%20charact%20%282015_04_26%2017_45_13%20UTC%29.jpg" width="1956" height="162" 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><span style="font-size: 13.008px; line-height: 20.0063px;">This strip shows a second-degree AV block.&nbsp; During most of the strip, 2:1 conduction is present.&nbsp; At the beginning, however, two consecutive p waves are conducted, revealing progressive prolongation of the PR interval.&nbsp; This usually represents a Type I , or nodal, block:&nbsp; progressive refractoriness of the AV node.&nbsp;&nbsp; However, the wide QRS ( possibly left bundle branch block), and the fact that the non-conducted p waves are "out in the open" where they should have conducted, points to Type II - an intermittant tri-fascicular block. Wenckebach periods in patients with LBBB can be caused by progressive conduction delay in the right bundle branch.</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/589/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: Second-degree AV Block With Characteristics of Type I and Type II 1/5</option><option value="40">Give ECG Basics: Second-degree AV Block With Characteristics of Type I and Type II 2/5</option><option value="60">Give ECG Basics: Second-degree AV Block With Characteristics of Type I and Type II 3/5</option><option value="80">Give ECG Basics: Second-degree AV Block With Characteristics of Type I and Type II 4/5</option><option value="100">Give ECG Basics: Second-degree AV Block With Characteristics of Type I and Type II 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--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-HoyVYlHkHuf_ZVQbapv8S5JASBgBo0opWB6XeJZmnwM" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</a></div><div class="field-item odd"><a href="/ecg/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item even"><a href="/ecg/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/av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AV Block</a></div><div class="field-item even"><a href="/ecg/wenckebach" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wenckebach</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-second-degree-av-block-characteristics-type-i-and-type-ii&amp;title=ECG%20Basics%3A%20%20Second-degree%20AV%20Block%20With%20Characteristics%20of%20Type%20I%20and%20Type%20II"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 01 Sep 2016 17:51:39 +0000 Dawn 709 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-second-degree-av-block-characteristics-type-i-and-type-ii#comments Supraventricular Tachycardia With Wenckebach Conduction https://www.ecgguru.com/ecg/supraventricular-tachycardia-wenckebach-conduction <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/supraventricular-tachycardia-wenckebach-conduction"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Wenckebach%20ST.jpg" width="1800" height="1013" alt="" /></a></div><div class="field-item odd"><a href="/ecg/supraventricular-tachycardia-wenckebach-conduction"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/RS%20Laddergram%20cropped.jpg" width="800" height="219" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">This ECG was obtained from a patient in a walk-in health clinic.&nbsp; We do not have any other information on the patient.&nbsp; We thank Joe Kelly for donating this interesting ECG to the GURU.</span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">IRREGULAR RHYTHM &nbsp; &nbsp;</span></strong><span style="font-size: 12pt; line-height: 107%;">If you march out the P waves, you will see that they are regular, at a rate of approximately 130 bpm.</span><span style="font-size: 12pt; line-height: 107%;">&nbsp; </span><span style="font-size: 12pt; line-height: 107%;">But the QRS complexes are not regular, and there are fewer QRS complexes than P waves.</span><span style="font-size: 12pt; line-height: 107%;">&nbsp;</span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">WENCKEBACH CONDUCTION &nbsp;&nbsp;</span></strong><span style="font-size: 12pt; line-height: 107%;">Looking closely at the PR intervals, you will notice that they progressively prolong.</span><span style="font-size: 12pt; line-height: 107%;">&nbsp; </span><span style="font-size: 12pt; line-height: 107%;">This “pushes” the QRS complexes progressively toward the right.</span><span style="font-size: 12pt; line-height: 107%;">&nbsp; </span><span style="font-size: 12pt; line-height: 107%;">Eventually, the T wave – and the refractory period – will land on the next P wave.</span><span style="font-size: 12pt; line-height: 107%;">&nbsp; </span><span style="font-size: 12pt; line-height: 107%;">That P wave will be unable to conduct to the wave, and no T wave of course, so the next P wave will conduct with a shorter PR interval.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">We are including a short rhythm strip from this patient, with conduction marked with a <a href="http://ecgguru.com/blog/are-you-new-laddergrams">laddergram.</a></span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">NOT A TYPICAL PRESENTATION &nbsp;&nbsp;</span></strong><span style="font-size: 12pt; line-height: 107%;">If your students have always learned “Second-degree AV block, Type I” or “Wenckebach” on a rhythm generator, they will expect to see a normal sinus rhythm, not sinus or atrial tach.</span><span style="font-size: 12pt; line-height: 107%;">&nbsp; </span><span style="font-size: 12pt; line-height: 107%;">They will also expect to see clearly repeating cycles of progressively prolonging PR intervals, until one P wave is non-conducted, producing a slight pause.</span><span style="font-size: 12pt; line-height: 107%;">&nbsp; </span><span style="font-size: 12pt; line-height: 107%;">They may not recognize the cause of the irregularity in this ECG unless they systematically analyze the P wave rhythm and then the QRS complexes and PR intervals.</span><span style="font-size: 12pt; line-height: 107%;">&nbsp; </span><span style="font-size: 12pt; line-height: 107%;">In this patient, V1 probably has the clearest P waves for analysis, and there is a continuous V1 rhythm strip on the bottom of the page.</span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">For those more advanced students, there are some “atypical” aspects to this ECG.&nbsp; You may notice that the FIRST P-QRST in each cycle has a PR interval of about .22 seconds, EXCEPT for the <strong>fourth beat on the 12-Lead ECG</strong>.&nbsp; This one appears to have a very SHORT PRI, but it is more likely that the PR interval was so LONG, the QRS appeared slightly AFTER the next P wave.&nbsp; <strong>What do you think?</strong></span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">BOTTOM LINE &nbsp; &nbsp;</span></strong><span style="font-size: 12pt; line-height: 107%;">We are hoping some of our experts, including our Consulting Expert, Dr. Grauer, will add more detailed comments to this ECG.</span><span style="font-size: 12pt; line-height: 107%;">&nbsp; </span><span style="font-size: 12pt; line-height: 107%;">The main points we would like to make on the most basic level are:</span></p><p class="MsoListParagraphCxSpFirst" style="margin-left: 31.5pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">1)<span style="font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-size: 12.0pt; line-height: 107%;">&nbsp;Real ECG rhythms may vary quite a bit from the basic examples seen on electronic rhythm generators, and in some brief references.</span><span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 31.5pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">2)<span style="font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-size: 12.0pt; line-height: 107%;">The “AV block” in this case is not a worrisome condition – it is more an expected lack of conduction due to a P wave landing in a refractory period.&nbsp; This is called “physiological block”.&nbsp; I would be more concerned about why this patient has tachycardia, and the clinical approach would be to evaluate the patient’s heart rate in light of his or her presenting symptoms.&nbsp;</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/589/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 Supraventricular Tachycardia With Wenckebach Conduction 1/5</option><option value="40">Give Supraventricular Tachycardia With Wenckebach Conduction 2/5</option><option value="60">Give Supraventricular Tachycardia With Wenckebach Conduction 3/5</option><option value="80" selected="selected">Give Supraventricular Tachycardia With Wenckebach Conduction 4/5</option><option value="100">Give Supraventricular Tachycardia With Wenckebach Conduction 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 >6</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-9H5LRehyHxvgR6Rjd8zBuSobBuwQryiA8_pntfm5IL0" /> <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-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial tachycardia</a></div><div class="field-item odd"><a href="/ecg/wenckebach" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wenckebach</a></div><div class="field-item even"><a href="/ecg/dual-av-pathways" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Dual AV pathways</a></div><div class="field-item odd"><a href="/ecg/laddergram" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Laddergram</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%2Fsupraventricular-tachycardia-wenckebach-conduction&amp;title=%20Supraventricular%20Tachycardia%20With%20Wenckebach%20Conduction"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 17 Mar 2016 04:55:46 +0000 Dawn 692 at https://www.ecgguru.com https://www.ecgguru.com/ecg/supraventricular-tachycardia-wenckebach-conduction#comments Second-Degree AV Block, Type I https://www.ecgguru.com/ecg/second-degree-av-block-type-i-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/second-degree-av-block-type-i-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB%20114_0.jpg" width="1800" height="877" 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><span style="font-size: 11pt; font-family: Verdana, sans-serif;">This ECG is from an 80-year-old woman who had an acute inferior wall M.I. with a second-degree AV block.<br /> &nbsp;<br /> Some people incorrectly call <strong>ALL</strong> second-degree AV blocks that are conducting 2:1 "Type II".&nbsp; This is incorrect, as Mobitz Type I can also conduct with a 2:1 ratio.&nbsp; The progressive prolongation of the PR interval will not be seen with a 2:1 conduction ratio, because there are not two PR intervals in a row.</span></p><p><span style="font-size: 11pt; font-family: Verdana, sans-serif;">This is a good example of a Type I, or Wenckebach, block which is initially conducting 2:1.&nbsp; At the end of the ECG, two consecutive p waves conduct, showing the "progressively-prolonging PR interval" hallmark of a&nbsp;Type I block. Type I blocks are supraHisian - at the level of the AV node -&nbsp;and generally not life-threatening.&nbsp;&nbsp;Blocks that are conducting 2:1 present a danger, however, in the effect they have on the rate.&nbsp; Whatever the underlying rhythm is, the 2:1 block will cut the rate in half!&nbsp; This patient has an underlying sinus tachycardia at 106, so her block has caused a rate of 53.&nbsp; In light of her acute M.I., that rate is probably preferable to the sinus tach. This patient’s BP remained stable, and she did not require pacing.</span><span style="font-size: 13.0080003738403px; line-height: 1.538em;">&nbsp;</span></p><p><span style="font-size: 11pt; font-family: Verdana, sans-serif;">The ST signs of acute M.I. are rather subtle here. Note the "coving upward" shape in Lead III, and the reciprocal depressions in I, aVL, V1, and V2. &nbsp;Type I blocks are common in inferior wall M.I., since the AV node and the inferior wall often share a blood supply - the right coronary artery.&nbsp;</span></p><p><span style="font-size: 11pt; font-family: Verdana, sans-serif;">While the print quality of this ECG is not the best, it is a great teaching ECG because it starts out with 2:1 conduction, then at the end of the strip, proves itself to be a Wenckebach block. &nbsp;&nbsp;</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/589/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 Second-Degree AV Block, Type I 1/5</option><option value="40">Give Second-Degree AV Block, Type I 2/5</option><option value="60">Give Second-Degree AV Block, Type I 3/5</option><option value="80">Give Second-Degree AV Block, Type I 4/5</option><option value="100" selected="selected">Give Second-Degree AV Block, Type I 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--6" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-rv_5itcFSU9R1CQ0qAA3X6m52LtXfvq_P6gQ1-ugeHs" /> <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/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AV Block</a></div><div class="field-item even"><a href="/ecg/second-degree-av-block-type-i" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Second-degree AV block Type I</a></div><div class="field-item odd"><a href="/ecg/wenckebach" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wenckebach</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%2Fsecond-degree-av-block-type-i-0&amp;title=Second-Degree%20AV%20Block%2C%20Type%20I"><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 Jun 2015 04:07:09 +0000 Dawn 644 at https://www.ecgguru.com https://www.ecgguru.com/ecg/second-degree-av-block-type-i-0#comments Acute Inferior Wall M.I. With Right Ventricular M.I. and Atrial Fibrillation https://www.ecgguru.com/ecg/acute-inferior-wall-mi-right-ventricular-mi-and-atrial-fibrillation <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-right-ventricular-mi-and-atrial-fibrillation"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWR100.jpg" width="1800" height="853" 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 style="margin-top: 0px; margin-bottom: 20px; outline: 0px; font-family: Verdana, Helvetica, Arial, sans-serif; font-size: 13px; font-stretch: inherit; line-height: 17.7272720336914px; clear: left;">This 31-year-old man presented to the Emergency Dept. complaining of chest pain, shortness of breath, and nausea. His heart rate on admission was 120 - 130 bpm and irregular, and the monitor showed atrial fibrillation. His rate slowed with the administration of diltiazem. His 12-lead ECG shows the classic ST elevation of inferior wall M.I. in Leads II, III, and aVF. This patient also had JVD, bibasilar rales, orthopnea, and exertional dyspnea, signs of CHF. He had no history of acute M.I., CHF, or atrial fibrillation. He offered no history of drug use or medications.</p> <p style="margin-top: 0px; margin-bottom: 20px; outline: 0px; font-family: Verdana, Helvetica, Arial, sans-serif; font-size: 13px; font-stretch: inherit; line-height: 17.7272720336914px; clear: left;">This ECG is very useful for the basic student, in that the ST elevations are readily seen, and the atrial fib is definitely irregularly-irregular. For the more advanced student, the ST depression in V2 indicates posterior wall injury, while the flat ST segment in V1 indicates a possible<a title="LITFL RVMI" href="http://lifeinthefastlane.com/ecg-library/right-ventricular-infarction/"> right ventricular M.I</a>. &nbsp;While the posterior wall is trying to depress the ST segment, the right ventricle is trying to elevate it, resulting in flattening. Also, Lead III has a greater STE than Lead II, which has been shown to be a reliable indicator of RV infarction. &nbsp;This should be confirmed with a V4 right, or all chest leads done on the right side. Right ventricular injury has been shown to increase mortality, and it also requires different management of hemodynamics.</p> <p style="margin-top: 0px; margin-bottom: 20px; outline: 0px; font-family: Verdana, Helvetica, Arial, sans-serif; font-size: 13px; font-stretch: inherit; line-height: 17.7272720336914px; clear: left;">It is unusual for a 31-year-old to experience acute M.I. &nbsp;That makes it important to rule out other causes of ST elevation and chest pain. &nbsp;Benign early repolarization and pericarditis should be considered. &nbsp;Some of the ECG signs that FAVOR the diagnosis of STEMI are: &nbsp;1) ST segments are straight, rather than curved downward like a smile. &nbsp;2) &nbsp;ST elevations are seen in related leads - leads oriented over the inferior wall and right ventricle (II, III, aVF, V1). &nbsp;3) Reciprocal ST depressions are seen in leads known to be reciprocal to the inferior leads (I, aVL) and leads reciprocal to the "upper" inferior wall, or posterior wall. &nbsp;4) There is an acute dysrhythmia (atrial fib). &nbsp;<a href="http://eurheartj.oxfordjournals.org/content/30/9/1038">Atrial fibrillation</a> is a fairly common complication of acute M.I., and also leads to increased mortality, especially when associated with CHF.</p> <p style="margin-top: 0px; margin-bottom: 20px; outline: 0px; font-family: Verdana, Helvetica, Arial, sans-serif; font-size: 13px; font-stretch: inherit; line-height: 17.7272720336914px; clear: left;"><span style="line-height: 17.7272720336914px;">This ECG can start a very instructive discussion on the relationship between acute M.I., acute CHF, and new-onset atrial fibrillation. That could be an entire class by itself!&nbsp;</span></p> <p style="margin-top: 0px; margin-bottom: 20px; outline: 0px; font-family: Verdana, Helvetica, Arial, sans-serif; font-size: 13px; font-stretch: inherit; line-height: 17.7272720336914px; clear: left;"><span style="line-height: 17.7272720336914px;">This patient was transferred to a nearby interventional cath lab, and his outcome is unknown.</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/589/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 Acute Inferior Wall M.I. With Right Ventricular M.I. and Atrial Fibrillation 1/5</option><option value="40">Give Acute Inferior Wall M.I. With Right Ventricular M.I. and Atrial Fibrillation 2/5</option><option value="60">Give Acute Inferior Wall M.I. With Right Ventricular M.I. and Atrial Fibrillation 3/5</option><option value="80">Give Acute Inferior Wall M.I. With Right Ventricular M.I. and Atrial Fibrillation 4/5</option><option value="100" selected="selected">Give Acute Inferior Wall M.I. With Right Ventricular M.I. and Atrial Fibrillation 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.8</span></span> <span class="total-votes">(<span >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-aEb55tRV98IsK6JhQVvCJeFSARrZpPxO10WgJ4TRqJ0" /> <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/inferior-wall-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior Wall M.I.</a></div><div class="field-item even"><a href="/ecg/right-ventricular-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right ventricular M.I.</a></div><div class="field-item odd"><a href="/ecg/atrial-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial fibrillation</a></div><div class="field-item even"><a href="/ecg/wenckebach" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wenckebach</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_7"> <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-right-ventricular-mi-and-atrial-fibrillation&amp;title=Acute%20Inferior%20Wall%20M.I.%20With%20Right%20Ventricular%20M.I.%20and%20%20Atrial%20Fibrillation"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 19 May 2015 17:10:40 +0000 Dawn 639 at https://www.ecgguru.com https://www.ecgguru.com/ecg/acute-inferior-wall-mi-right-ventricular-mi-and-atrial-fibrillation#comments ECG Challenge: Grouped Beating - Double Tachycardia - ANSWER https://www.ecgguru.com/ecg/ecg-challenge-grouped-beating-double-tachycardia-answer <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-grouped-beating-double-tachycardia-answer"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/1%20Junctional%20tachycardia.jpg" width="1239" height="202" alt="" /></a></div><div class="field-item odd"><a href="/ecg/ecg-challenge-grouped-beating-double-tachycardia-answer"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/2%20Laddergram.jpg" width="1731" height="344" alt="" /></a></div><div class="field-item even"><a href="/ecg/ecg-challenge-grouped-beating-double-tachycardia-answer"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/3%20Laddergram.jpg" width="1678" height="275" alt="" /></a></div><div class="field-item odd"><a href="/ecg/ecg-challenge-grouped-beating-double-tachycardia-answer"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/4%20Laddergram.jpg" width="1665" height="295" alt="" /></a></div><div class="field-item even"><a href="/ecg/ecg-challenge-grouped-beating-double-tachycardia-answer"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/5%20Laddergram.jpg" width="1357" height="300" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong>This series of strips was donated by Arnel Carmona, and was taken from a patient admitted to the hospital for a urinary tract infection. &nbsp;No other history is known. &nbsp; On close examination of this rhythm what do we see?</strong></p><p class="MsoNormal"><span style="font-size: 9.0pt;">Strip 1: &nbsp;&nbsp;Narrow-complex tachycardia with NO apparent P waves.</span></p><p class="MsoNormal"><span style="font-size: 9.0pt;">Strip 2: &nbsp;&nbsp;Some irregularity, with long regular groups and still NO P waves.</span></p><p class="MsoNormal"><span style="font-size: 9.0pt;">Strips 3 &amp; 4:&nbsp; Grouped beating.</span></p><p class="MsoNormal"><span style="font-size: 9.0pt;">Strip 5:&nbsp; &nbsp;A narrow-complex rhythm that is approximately ½ the rate of Strip 1.</span><span style="font-size: 13.0080003738403px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal">When grouped beating is seen, one should always suspect Wenckebach conduction.&nbsp; Wenckebach conduction (progressively longer conduction times through the A-V conduction system) can occur in rhythyms other than sinus rhythm.&nbsp; Without P waves and PR intervals, GROUPED BEATING is our major clue to Wenckebach conduction.<span style="font-size: 13.0080003738403px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal">This patient has an underlying atrial fibrillation – hence no P waves.&nbsp; Fine fibrillatory waves can be seen, but artifact can cause the same appearance.&nbsp; So, why is there no irregular irregularity?&nbsp; There is another rhythm at work here along with the atrial fibrillation.&nbsp; Junctional tachycardia is seen in Strip 1.&nbsp; When two tachycardias coexist, one from above the AV junction, and one from below, the rhythm can be called a “double tachycardia”.&nbsp; This particular combination often happens in patients with digitalis toxicity.<span style="font-size: 9pt; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal">In some cases, a complete heart block at the level of the atrial conduction fibers or the AV node causes &nbsp;two rhythms to operate independently.&nbsp; Any supraventricular rhythm, including atrial fib, can occur with a complete heart block, in which case we would see an “escape” rhythm.&nbsp; Escape rhythms are usually slow, either idiojunctional (40-60 bpm) or idioventricular (&lt; 40 bpm).&nbsp;<span style="font-size: 13.0080003738403px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal">&nbsp;Let’s look at each of the strips in detail.&nbsp; We will begin with the hypothesis that this is atrial fibrillation with concurrent junctional tachycardia at around 150 bpm.&nbsp; I will include laddergrams to illustrate my view of what is happening.<span style="font-size: 13.0080003738403px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" style="margin-left: 1.0in; text-indent: -1.0in;"><span style="font-size: 10.0pt;">Strip 1 :&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Junctional tachycardia at around 148-150/min.&nbsp; Differential diagnosis would include sinus tach with 1<sup>st</sup> degree AV block, but we have no evidence in this strip of P waves in the T waves. There is presumably an <strong>entrance block</strong> to the AV node, preventing retrograde P waves from the AV junction from entering the atria.</span></p><p class="MsoNormal" style="margin-left: 1.0in; text-indent: -1.0in;"><span style="font-size: 10.0pt;">Strip 2:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; In this strip, I feel less confident of my hypothesis, but have been able to construct a laddergram that is consistent with a fib and junctional tach with Wenckebach exit block.</span><span style="font-size: 10pt; text-indent: -1in; line-height: 1.538em;">&nbsp; &nbsp; &nbsp;</span><span style="font-size: 10pt; text-indent: -1in; line-height: 1.538em;">I would, as always, welcome input.</span></p><p class="MsoNormal" style="margin-left: 1.0in; text-indent: -1.0in;"><span style="font-size: 10.0pt;">Strip 3:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Now, the grouped beating is very evident.&nbsp; I have mapped out on the laddergram where the beats originate in the AV junction, and where they become a QRS.&nbsp; You can see progressive prolongation in these impulses traveling to the ventricles.&nbsp;&nbsp; There are no P waves because of the atrial fib and the block preventing junctional beats from traveling backward into the atria.</span></p><p class="MsoNormal" style="margin-left: 1.0in; text-indent: -1.0in;"><span style="font-size: 10.0pt;">Strip 4: &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The group beating has taken the form of couplets.&nbsp; The rhythm looks like sinus with PACs, but WAIT …… <strong>no P waves</strong>, remember?</span></p><p class="MsoNormal" style="margin-left: 1.0in; text-indent: -1.0in;"><span style="font-size: 10.0pt;">Strip 5:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Now, the junctional beats are conducting 2:1, and the rate is half what it was in Strip 1, when conduction was 1:1.</span></p><p class="MsoNormal" style="margin-left: 1.0in; text-indent: -1.0in;"><span style="font-size: 10.0pt;">These links may be helpful to you. &nbsp;Discussion of double tachycardia with a fib and junctional tach in <a title="EP Europace Double Tachy" href="http://dx.doi.org/10.1093/europace/eun172">EP Europace</a>. &nbsp;Discussion of atrial fib and Wenckebach in digitalis toxicity by <a title="Grauer Dig Tox A Fib" href="https://www.dropbox.com/s/bga1xtrk33z9nt8/AFib-Wenckebach%20Dig%20Toxicity-Grauer.pdf?dl=0/">Dr. Ken Grauer</a>. &nbsp;Original posting of strips on Arnel Carmona's website, <a title="ECG Rhythms Double Tachy" href="http://wp.me/p4vvFu-jO">ECG Rhythms</a>. &nbsp;These strips are the property of Arnel Carmona and should be used only in an educational context. &nbsp;For any other use, contact <a href="mailto:Dawn.ECGGuru@gmail.com">Dawn.ECGGuru@gmail.com</a>. &nbsp;</span></p><p class="MsoNormal" style="margin-left: 1.0in; text-indent: -1.0in;">&nbsp;<span style="font-size: 13.0080003738403px; line-height: 1.538em;">Thanks so much to Arnel Carmona for this excellent teaching series.&nbsp; We hope you will add your comments and/or questions below.</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/589/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 Challenge: Grouped Beating - Double Tachycardia - ANSWER 1/5</option><option value="40">Give ECG Challenge: Grouped Beating - Double Tachycardia - ANSWER 2/5</option><option value="60">Give ECG Challenge: Grouped Beating - Double Tachycardia - ANSWER 3/5</option><option value="80">Give ECG Challenge: Grouped Beating - Double Tachycardia - ANSWER 4/5</option><option value="100" selected="selected">Give ECG Challenge: Grouped Beating - Double Tachycardia - ANSWER 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.1</span></span> <span class="total-votes">(<span >8</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--8" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-RkOKE92ScCppeWmkj3wiP5CVBCxWUNuZsTo1K8kS-mA" /> <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/double-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Double tachycardia</a></div><div class="field-item odd"><a href="/ecg/atrial-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial fibrillation</a></div><div class="field-item even"><a href="/ecg/junctional-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional tachycardia</a></div><div class="field-item odd"><a href="/ecg/wenckebach-conduction" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wenckebach Conduction</a></div><div class="field-item even"><a href="/ecg/ecg-challenge" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Challenge</a></div><div class="field-item odd"><a href="/ecg/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item even"><a href="/ecg/wenckebach" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wenckebach</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-challenge-grouped-beating-double-tachycardia-answer&amp;title=ECG%20Challenge%3A%20Grouped%20Beating%20-%20Double%20Tachycardia%20-%20ANSWER"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 04 Feb 2015 01:06:09 +0000 Dawn 620 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-challenge-grouped-beating-double-tachycardia-answer#comments ECG Challenge: Grouped Beating - Double Tachycardia https://www.ecgguru.com/ecg/ecg-challenge-grouped-beating-double-tachycardia <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-grouped-beating-double-tachycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Double%20tachycardia%20without%20reference%20laddergram%20from%20another%20source.jpg" width="1710" height="1069" 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 very interesting set of strips was donated to the ECG Guru by Arnel Carmona, well-known to many of you as the Administrator of the blog, "<a href="https://ecgrhythms.wordpress.com/">ECG Rhythms</a>" and the <a title="ECG Guru" href="https://www.facebook.com/pages/ECG-Rhythms/219229508179704">FB page</a> by the same name. &nbsp;He is a frequent contributer to the FB page, "<a title="EKG Club" href="https://www.facebook.com/groups/ekgclub/">EKG Club</a>", and is an ECG Guru! &nbsp;This set of strips was previously posted to his blog and to the EKG Club. &nbsp;In case you haven't already seen it, we will withhold the interpretation for now to give everyone a chance to comment. &nbsp;In one week, we will post the interpretation.</p><p><a title="Double Tachycardia LINK" href="http://ecgguru.com/ecg/ecg-challenge-grouped-beating-double-tachycardia-answer">SEE THE INTERPRETATION AT THIS LINK</a></p><p>*********************************************************************************************</p><p><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">Can Atrial Fibrillation be regular?</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">This strip is from a pt admitted for UTI.</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">This cropped lead II strip is from several hours of saved data and specifically posted in order and not necessarily in chronology to highlight a point.</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">1 - You can see a regular narrow complex tachycardia (NCT) at a rate of about 140’s. How will you read it? SVT? Atrial flutter? AF with RVR? ST with P waves buried in the T waves?</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">2 - There is still a regular NCT but there is a slowing with no discernible P waves. So AF RVR?</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">3- The same regular NCT but you can see &nbsp;regularly-irregular QRS activity. Isn’t it that AF should be irregular and will not show any regularity?</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">4 - There are groups of 2 QRS with same R to R intervals. It is called GROUP BEATING.</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">5- There is a regular RR interval at a rate of about 70's with no discernible P waves. REGULARIZED AF?</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">A few interesting things the strip revealed:</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">1. The fastest rate was about 140's and the regularized rate was about 70's.</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">2. There is group beating. For beginners, it is hard to see the group beating but probably as you mature or, as you get so crazy and obsessed in looking at strips, &nbsp;then you see it. &nbsp;A few people would and most won't.</span><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><span style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;">Most of us will think, can this be atrial flutter? This is what my other good friends in the ECG Club thought. I checked more than 72 hrs of tele-recordings and could not find the flutter waves. (BTW pt had chronic AF)</span></p><p>What do you think?</p><p><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /><br style="color: #222222; font-family: arial, sans-serif; font-size: 12.7272720336914px; line-height: normal;" /></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/589/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 ECG Challenge: Grouped Beating - Double Tachycardia 1/5</option><option value="40">Give ECG Challenge: Grouped Beating - Double Tachycardia 2/5</option><option value="60">Give ECG Challenge: Grouped Beating - Double Tachycardia 3/5</option><option value="80" selected="selected">Give ECG Challenge: Grouped Beating - Double Tachycardia 4/5</option><option value="100">Give ECG Challenge: Grouped Beating - Double Tachycardia 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 >3</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-8JG1rGBRlfTWgWxPp2y8S_ro41z8ierrpZMIDrBL1GE" /> <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-challenge" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Challenge</a></div><div class="field-item odd"><a href="/ecg/double-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Double tachycardia</a></div><div class="field-item even"><a href="/ecg/atrial-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial fibrillation</a></div><div class="field-item odd"><a href="/ecg/junctional-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional tachycardia</a></div><div class="field-item even"><a href="/ecg/wenckebach-conduction" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wenckebach Conduction</a></div><div class="field-item odd"><a href="/ecg/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item even"><a href="/ecg/wenckebach" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wenckebach</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%2Fecg-challenge-grouped-beating-double-tachycardia&amp;title=ECG%20Challenge%3A%20%20Grouped%20Beating%20-%20Double%20Tachycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 25 Jan 2015 23:42:00 +0000 Dawn 615 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-challenge-grouped-beating-double-tachycardia#comments Second-degree AV Block, Type I https://www.ecgguru.com/ecg/second-degree-avb-type-i <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/second-degree-avb-type-i"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB112.jpg" width="1800" height="635" 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 67 year old man is noted to have a slightly irregular pulse.&nbsp; At the beginning of this ECG, he appears to be in NSR with a first-degree AV block.&nbsp; Twice, P waves are non-conducted.&nbsp; Careful measurement of the P to P interval shows that it is regular, there are no PACs noted.&nbsp; The PR interval changes very subtly by lengthening just before the&nbsp;non-conducted P waves.&nbsp; A hint when non-conducted P waves are noted, first check for non-conducted PACs.&nbsp; If the&nbsp;sinus rhythm is regular, check the PR interval before the non-conducted beat, and the PR interval immediately after the non-conducted beat.&nbsp; You will see the PRI preceding the&nbsp;non-conducted P is longer than the PRI after the NCP.</p><p>Wenckebach conduction is caused by RP/PR reciprocity.&nbsp; In other words, the shorter the RP interval, the longer the PR interval.&nbsp; So, as the PRI lengthens, the QRS "moves" to the right, eventually causing the next regular sinus P wave to fall into the refractory period and fail to conduct.&nbsp; This results in a pause, or a long RP interval, which shortens the next PRI.&nbsp;</p><p>&nbsp;If you or your students would like to review AV Blocks, go to this <a href="https://www.kg-ekgpress.com/upload/ECG_PDF_Course_-_3-12-2011/AV_Block-NEW_(11-19.21-2011)-Handout-LOCK.pdf">LINK</a> for Dr. Grauer's excellent, FREE, self-directed tutorial.</p><p>For a slightly more advanced discussion of RP/PR reciprocity, see <a title="RP-PR Reciprocity" href="http://www.ekgguru.com/content/how-do-you-explain-changing-pr-intervals-following-series-strips-and-mechanism-related">Jason's Blog</a>.</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/589/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 Second-degree AV Block, Type I 1/5</option><option value="40">Give Second-degree AV Block, Type I 2/5</option><option value="60">Give Second-degree AV Block, Type I 3/5</option><option value="80">Give Second-degree AV Block, Type I 4/5</option><option value="100" selected="selected">Give Second-degree AV Block, Type I 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 >6</span> votes)</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-52pGIWPEQgIimn9DAOEYPH2ix2ujbjdLa47X23gC3no" /> <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/wenckebach" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wenckebach</a></div><div class="field-item odd"><a href="/ecg/second-degree-av-block-type-i" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Second-degree AV block Type I</a></div><div class="field-item even"><a href="/ecg/av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">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_10"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fsecond-degree-avb-type-i&amp;title=Second-degree%20AV%20Block%2C%20Type%20I"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 17 Feb 2013 00:52:05 +0000 Dawn 402 at https://www.ecgguru.com https://www.ecgguru.com/ecg/second-degree-avb-type-i#comments