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This ECG shows a second-degree AV block, Mobitz Type II. It is also called “high grade AV block” because there is a 3:1 ratio of P waves to QRS complexes and a resulting slow rate.
Right bundle branch block and left anterior fascicular block are also present, as is common with Type II blocks. The underlying rhythm is sinus. Second-degree AVB, Type II, usually represents an intermittent tri-fascicular block: often right bundle branch block and left anterior fascicular block (hemiblock) are present, and the left posterior fascicle develops an intermittent block. During times of tri-fascicular block, the P waves are not conducted. When the posterior fascicle is conducting, a QRS occurs.
A differential diagnosis for this ECG is complete heart block with ventricular escape rhythm. A longer strip would be needed to see the P waves eventually dissociate from the QRSs, if they are going to do so. Clinically, there is really little difference in the treatment of a high-grade "second degree" block and a "third degree" block. Both are treated with emergency support of the slow rate, as needed, and then a permanent implanted pacemaker.
It is notable that, in this case, the interpretation given by the machine is completely incorrect, even including the intervals. This is not common, but does occur. The machine's interpretation should be considered, but not followed blindly.
This patient has an underlying atrial fibrillation with complete heart block and an idioventricular escape rhythm. She was treated successfully with a permanent implanted pacemaker.
To continue on a topic started by Jason Roediger in his February ECG Challenge -
This series of two ECGs was taken from a 71-year-old man who complained of dizziness and near-syncope the day before these ECGs were done. He was seen in an Emergency Dept., and advised to follow up with a neurologist. On the day of these ECGs, still feeling dizzy and like he would pass out, he called EMS again. He denied chest pain. We do not know his past medical history. The first ECG was taken at 10:22 am. His BP was 177/76 and SpO2 99%. It shows a regular sinus rhythm (p waves marked by small asterisks) at a rate of about 75 / min. There is a high-grade AV block, meaning that some P waves are conducted (beats 2, 4, 7), but most are not. In addition, he has an escape rhythm, probably ventricular, at a rate of just over 40 / min. The overall effect of the escape rhythm is to keep the heart rate above 40 beats per minute.
Fifteen minutes later, at 10:37 am, another ECG is taken. The patient's BP is 154/86. This ECG shows the high-grade AV block quite well, but this time, most of the QRS complexes on the strip are conducted from P waves. It is difficult to see all the P waves in every lead, but if you remember that all three channels are run simultaneously, you will find evidence of the P waves in at least one of the three leads represented at any given time. (Example: V1, V2, and V3 - V3 shows the P waves well). The next-to-last QRS on the page is interesting, as it has a different PRI than the normally conducting beats. Is this a fusion beat or an aberrantly-conducted one? It probably does not matter to the outcome of the patient.
The slowing of the rate in the second strip gives us a clue as to why the patient felt dizzy, but the blood pressures recorded did not catch hypotension. Possibly if the patient had been standing instead of lying on a stretcher, we would have seen more hemodynamic changes.
Unfortunately, we do not know the outcome of this patient, but it seems he is a candidate for an implanted pacemaker.
This week's ECG of the Week is from an elderly woman who suffered an acute occlusion of the right coronary artery. The ECG clearly shows ST elevation in leads II, III, and aVF, indicating inferior wall injury. In this case, this ECG was obtained in the field by paramedics, and was the second ECG done on this patient. For this tracing, the paramedics obtained V3 and V4 on the right side to better view the right ventricle. V3 and V4 right clearly show ST elevation as well, indicating RVMI. The slight coving and elevation observable in V1 is also an indication of RV involvement, and the ST depression in V2 indicates posterior wall injury. All of this results from a proximal lesion of the RCA in this patient. Such a lesion carries a high morbidity and mortality.
Taking the time to obtain a right ventricular lead is controversial in some settings. Some believe the patient's hemodynamic condition should be treated, regardless of the presence or absence of ST elevation in right chest leads. Others find it very helpful to know that the right ventricle is affected. In this case, paramedics in this community have a protocol to avoid the use of nitroglycerine in RVMI patients, even when the BP is adequate. So, for them, it is important to have the information gathered from V Right leads.
The rhythm here is interesting, as well, and not at all uncommon for IWMI patients. The baseline artifact makes it a bit difficult to march out all the P waves, but it appears they are sinus P waves that are slightly irregular at a rate of 52 to 54. The PR intervals appear to be progressively prolonging, but there is no "grouped beating" observable on this short strip. A lack of a concurrent Lead II rhythm strip also makes it difficult to determine the rhythm, as Lead II does have very visible P waves, and would be helpful. The regularity of the narrow complex bradycardia points to a junctional escape rhythm, which would make this a third-degree AVB at the AV node level, which is very common with IWMI. What do you think?
This month's strip from Jason Roediger's ECG Challenge blogpost is a nice complement to the strip presented here. His is much clearer, and has a Lead II rhythm strip. Do you think these ECGs show the same rhythm, or two different rhythms?
For an excellent discussion of "AV Dissociation" vs. "AV Block", go to Christopher Watford's Ask the Expert post. Thanks very much to ECG Guru Sebastian Garay for this interesting ECG.
QUESTION: How do you explain the difference between "AV block" and "AV dissociation" to your students?
Our Expert today is Christopher Watford, BSc, NREMT-P
Christopher began in EMS as an EMT on a volunteer industrial fire brigade at GE's Global Nuclear Fuels facility in Wilmington, North Carolina. He has worked there as a Lead Software Engineer since 2001 and currently is a Captain on the fire brigade. Outside of his day job, he volunteers as a Paramedic and Field Training Officer for Leland Volunteer Fire/Rescue where he also serves on the board of directors.Through Cape Fear and Brunswick Community Colleges heteaches continuing educat ation for all levels of providers. He also is an associate editor for the EMS 12-Lead Blog and Podcast, presenting electrocardiography case studies for pre-hospital personnel.
I think the first step in understanding the difference between an atrioventricular block and atrioventricular dissociation is to have a firm understanding of physiological and pathological conduction. The most common example of this is a non-conducted premature atrial contraction (PAC). If an atrial stimulus arrives early enough at the atrioventricular node (AVN), while it is still refractory, forward conduction will be blocked. Likewise in atrial flutter, you typically see one ventricular activation for every two F-waves, due to the physiological rate limiting by the AVN. However, as this is due to the physiological function of the AVN we would not consider this a block!
In higher degree AV blocks, we encounter a pathological decrease in conduction and so we label non-conducted stimuli as "blocked". Type I and Type II AV blocks provide visual confirmation of pathological conduction as you have examples of both conducted and non-conducted stimuli. However, in the case of a presumed complete AV block, it is important that you look at whether the atrial impulses were blocked or simply not conducted. With monomorphic ventricular tachycardia you may see uncoordinated atrial and ventricular impulses on the ECG. In this case the ventricular rhythm and the atrial rhythm "compete" for access to the AV nodal tissue. There is no "AV block" present, instead we say they are "dissociated" from the ventricular rhythm. More specifically, we say that the atrial rhythm is dissociated from the ventricular rhythm due to usurpation. Best illustrating the competitive nature of two rhythms during dissociation are capture or fusion beats.
Therefore when classifying dyssynchrony between the atria and ventricles, students should look to see whether conduction blocked due to pathological processes or because the AV node is appropriately refractory.
This ECG has always caused a lively conversation in ECG classes, both beginner classes and advanced. There is an obvious underlying sinus tachycardia, with clear P waves.
Some propose that the ECG shows a second-degree AVB, Type II, in that the PR intervals are constant, or nearly so. There is a slight discrepency if you compare the first PRI with the others. The QRS complexes, while very slow, have a pattern of right bundle branch block with left anterior fascicular block - not an unlikely finding in second-degree AV block, Type II, since that is a block in the fascicles of the interventricular conduction system. Type II blocks usually are accompanied by signs of bundle branch dysfunction.
Others strongly believe this is a third-degree, or complete, heart block. They argue that the PR intervals are not identical, and propose that a longer strip would uncover the discrepency. The wide QRS complexes have a strong left axis deviation, which could support the argument for idioventricular escape rhythm.
What do you think? Please comment below.
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