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Dawn's picture

Instructors' Collection ECG: Ventricular Standstill

The Patient: This 72-year-old woman called EMS because of a sudden onset of breathlessness and anxiety. She had a history of COPD (asthma), CHF, and Type II diabetes. We do not know her medications or any other history. She was found to have bilateral breath sounds with "minimal" expiratory wheezing. She was alert and very anxious. Her initial pulse rate was recorded at around 60 bpm and irregular. A systolic BP was heard at 140 mm Hg, but the paramedic could not hear a pulse after that. She was given oxygen via CPAP (Continuous positive airway pressure). The first ECG at 15:50 was recorded during this assessment. After appearing to improve, she became neurologically altered, and her level of consciousness varied during the call. She was turned over to emergency department staff conscious and able to speak, but had a cardiac arrest subsequently. The paramedics were unable to obtain followup information regarding the outcome.

ECG at 1550: The first QRS on the recording has no associated P wave, and is presumed to be an escape beat, probably junctional, with an interventricular conduction delay (QRS .12 sec.). This is a right bundle branch block pattern with left anterior fascicular block (bifascicular block). The second QRS is about the same width, but with a different morphology and discordant T waves, so probably ventricular. The third QRS is very much like the first, except that it appears to be conducted from the preceding P wave. For the next five seconds, there are only P waves, which are regular at about 130 bpm. The three-beat pattern seen at the beginning repeats itself near the end.

This ECG shows evidence of severe conduction blocks. The wide QRS complexes indicate interventricular blocks. In this case, some are probably premature ventricular contractions and some are sinus beats with bifascicular block. Even more worrisome is the intermittent loss of AV conduction. This can be called "intermittent trifascicular block", or "intermittent ventricular standstill". This is not a "third-degree AV block", because there are signs of AV conduction, but it is very close. With two of the three main fasicles of the left bundle branch blocked initially, it only takes a block in the remaining fascicle to produce a complete lack of AV conduction. Of course, there are no pulses during the time of ventricular standstill. The really concerning part of this situation is the lack of an ESCAPE RHYTHM. This is a good time for a temporary pacemaker, either transcutaneous or, if available, transvenous.

Dr A Röschl's picture

ATRIAL FIBRILLATION

Unfortunately, I can't remember who the author of this ECG is. Perhaps he/she will get in touch with me. However, the ECG is very nice (despite the less than optimal recording quality) and that's why I want to post it. I don't know the history.
In the first section of the ECG we see coarse fibrillation waves and QRS complexes with very different RR intervals, which is why this is atrial fibrillation. It is not atrial flutter because the fibrillation waves are of different size and polarity (depending on the lead) and the intervals between the atrial actions are irregular.

Dr A Röschl's picture

NONSUSTAINED VT

Extract from a Holter ECG, 2 continuous strips, recorded at 25 mm/s. At the top you can see a broad complex tachycardia without recognizable P waves, which ends spontaneously after 2 beats in the lower section. This is a ventricular tachycardia (VT). The very first beat in the 1st strip is most probably a fusion beat. After the end of the VT in the 2nd strip, a narrow QRS complex appears, here you can also recognize that atrial fibrillation is present.

Dr A Röschl's picture

PVCS and MORE

Sometimes you see an ECG strip, look at it and then put it away again with the thought: I don't understand this. But if you take your time and analyze the ECG systematically, you will usually come to a good result. This is an example of such an ECG (certainly not the most difficult). The explanation is shown in the 2nd picture.

Dawn's picture

For Fans of Dr Jerry W Jones

“Jerry W. Jones, MD FACEP FAAEM is pleased to announce the move from LinkedIn to his ECG education website: https://medicusofhouston.com/ . Join him there for his popular twice weekly posts on ECG topics for beginners through advanced and announcements regarding his Masterclasses and book releases.” I want to thank all of you for your interest in my teaching and in electrocardiography. I hope to see you in one of my Masterclasses soon! And I hope to hear from you in my new location! Jerry W. Jones, MD FACEP FAAEM

Dr A Röschl's picture

Sick Sinus Syndrome

The ECG shows an example of a patient with bradycardia/tachycardia syndrome (also called sick sinus syndrome). Initially, a sinus rhythm with a heart rate of approx. 70 bpm is seen. This is followed by sinus arrest of just under 3000 ms, followed by a junctional escape beat (no preceding P wave, QRS remains narrow). After a further pause of just under 2000 ms, 2 sinus node beats follow, which merge into a sinus tachycardia or atrial tachycardia (heart rate approx. 120 bpm here).

Dr A Röschl's picture

AV Nodal Reentry Tachycardia on a Holter Monitor Strip

The first 3 beats are sinus node beats, all have the same morphology of the P wave. This is followed by a PAC, which is conducted via the fast pathway in the AV node. The next PAC is conducted via the slow pathway, then the AV nodal reentry tachycardia (slow/fast) starts. The retrograde P waves are visible at the end of the QRS complex in the lower lead K3.

Dr A Röschl's picture

PVCs With VA Conduction

Why is the pause after the PVCs relatively long? We see a sinus arrhythmia in the rhythm strip. The ventricular extrasystoles penetrate the AV node retrogradely and reset the sinus rhythm, which then restarts. VA conduction can be recognized by the inverted P wave following the QRS complex of the ventricular extrasystole (PVC).

Dr A Röschl's picture

PVCs And Their Relationship to P waves, Some Examples

In order to differentiate supraventricular extrasystoles/tachycardias with aberrant conduction from ventricular extrasystoles/tachycardias, the search for P waves is often very important. Here are some examples of how the P waves can be positioned around the ventricular extrasystoles.

Dr A Röschl's picture

Complete Right Bundle Branch Block With AV Block and More

This is the ECG of a 50-year-old man with a congenital heart defect (we do not have exact details).
To interpret an ECG with several different abnormalities, you have to proceed systematically. You can see my comments in the second picture. Perhaps Dawn would like to add something?

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ECG HISTORY:     ECG was first put into clinical use in the early 1900s.  In 1909, it helped diagnose an arrhythmia.  A year later, indications of a heart attack were noted.

 

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