First-degree AV block https://www.ecgguru.com/taxonomy/term/179/all en Impending Trifascicular AV Block https://www.ecgguru.com/blog/impending-trifascicular-av-block <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/impending-trifascicular-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/impending.jpg" width="2578" height="1580" 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>Here we see the EKG of a 63-year-old man with CAD without relevant coronary stenosis. He complains of slightly reduced performance, but no other symptoms. The ECG shows the following changes:<br /></p></div></div></div> Mon, 28 Aug 2023 12:24:38 +0000 Dr A Röschl 867 at https://www.ecgguru.com Ask The Expert https://www.ecgguru.com/expert-review/ask-expert-14 <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 class="MsoNormal" style="margin-bottom: 0in; line-height: 15.0pt; background: white; vertical-align: baseline;"><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in; mso-no-proof: yes;"><span style="mso-spacerun: yes;"><span style="font-family: 'Lucida Sans Unicode', sans-serif;"><span style="font-size: 16px;"><strong>Today's Expert is Dr. Jerry Jones, MD, FACEP, FAAEM</strong></span></span><span style="font-family: Verdana, sans-serif;"><span style="font-size: 9pt;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; </span></span></span></span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: 15.0pt; background: white; vertical-align: baseline;"><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in; mso-no-proof: yes;"><span style="mso-spacerun: yes;"><span style="font-family: Verdana, sans-serif;"><span style="font-size: 9pt;">&nbsp;J</span></span></span></span><span style="font-family: Verdana, sans-serif; font-size: 9pt;">erry W. Jones, MD FACEP FAAEM is a diplomate of the American Board of Emergency Medicine who has practiced internal medicine and emergency medicine for 35 years.&nbsp; &nbsp;&nbsp;<img src="/sites/default/files/pictures/Profile%20photo.jpg" width="96" height="100" style="float: right;" /></span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: 15.0pt; background: white; vertical-align: baseline;"><span style="font-family: Verdana, sans-serif; font-size: 9pt;">Dr. Jones has been on the teaching faculties of the University of Oklahoma and The University of Texas Medical Branch in Galveston. He is a published author who has also been featured in the New York Times and the Annals of Emergency Medicine for his work in the developing field of telemedicine. He is also a Fellow of the American College of Emergency Physicians and a Fellow of the American Academy of Emergency Medicine and, in addition, a member of the European Society of Emergency Medicine.&nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal; background: white; vertical-align: baseline;"><span style="font-size: 10.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black;">&nbsp;</span><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">Dr. Jones is the CEO of</span><span><a title="Medicus of Houston Website" href="http://www.medicusofhouston.com/"><span style="font-size: 9.0pt; font-family: 'inherit',serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: #0062a0; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">&nbsp;Medicus of Houston</span></a></span><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">&nbsp;and the principal instructor for the&nbsp;</span><span><a href="https://medicusofhouston.com/"><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: #0062a0; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">Advanced ECG Interpretation Boot Camp and the Advanced Dysrhythmia Boot Camp</span></a></span><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">.&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span><span style="font-size: 9pt; font-family: Verdana, sans-serif;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal; background: white; vertical-align: baseline;">&nbsp;</p><p class="MsoNormal"><strong><span style="font-size: 18.0pt; line-height: 107%; color: #00b050;">Question:</span></strong><span style="font-size: 20.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">I teach beginner students. How can I explain the complex subject of “AV Blocks”? <span style="mso-spacerun: yes;">&nbsp;</span>I don’t want to teach incorrect information while trying to simplify the subject.</span></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal; background: white; vertical-align: baseline;">&nbsp;</p><p class="MsoNormal"><strong><span style="font-size: 18.0pt; line-height: 107%; color: #00b050;">&nbsp;Answer:&nbsp; <a title="AV Blocks article" href="https://www.ecgguru.com/ecg-resource/av-blocks-dr-jerry-jones">AV Blocks Article By Dr. Jerry Jones&nbsp; (click link)</a></span></strong></p><p class="MsoNormal" style="margin-bottom: 0in; line-height: normal; background: white; vertical-align: baseline;"><a title="AV Blocks article" href="https://www.ecgguru.com/ecg-resource/av-blocks-dr-jerry-jones"><span style="font-size: 9.0pt; font-family: 'Verdana',sans-serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; color: black; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;"><br /></span></a></p></div></div></div> Sun, 20 Dec 2020 18:02:21 +0000 Dawn 795 at https://www.ecgguru.com ECG Basics: Second-degree AV Block, Type II https://www.ecgguru.com/ecg/ecg-basics-second-degree-av-block-type-ii-0 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics-second-degree-av-block-type-ii-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/167%20AVB%20Type%20II%203%20to%202.jpg" width="1398" height="279" 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 was obtained from a man who was suffering an acute inferior wall M.I.&nbsp; There are ST elevation and hyperacute T waves.&nbsp; The rhythm is <strong>SINUS ARRHYTHMIA WITH SECOND-DEGREE AV BLOCK, TYPE II.&nbsp; &nbsp;</strong> There is also first-degree AV block.</p><p>There are more P waves than QRS complexes, with a 3:2 ratio.&nbsp; The atrial rate varies between 55 -68 beats per minute.&nbsp; The sinus rate speeds slightly after the dropped QRS in each group. The ventricular rate is about 40 bpm, with grouped beating. (Regularly irregular.)</p><p>The PR intervals are steady at 226 ms (slightly prolonged).</p></div></div></div> Tue, 08 Dec 2020 21:31:26 +0000 Dawn 794 at https://www.ecgguru.com High-grade AV Block With Profound Bradycardia https://www.ecgguru.com/ecg/high-grade-av-block-profound-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/high-grade-av-block-profound-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB120%20High%20grade%20w%20sinus%20brady.jpg" width="1800" height="768" 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">If you are an ECG instructor, you probably carefully choose ECGs to illustrate the topic you are teaching. One of the reasons for the existence of the ECG Guru website is our desire to provide lots of such illustrations for you to choose from.</p><p class="MsoNormal">Sometimes, though, an ECG does not clearly illustrate one specific dysrhythmia well, because the interpretation of the ECG depends on so many other factors.<span style="mso-spacerun: yes;">  </span>In order to get it “right”, we would need to know information about the patient’s history, presentation, lab results, or previous ECGs. We might need to see the ECG done immediately before or after the one we are looking at.<span style="mso-spacerun: yes;">  </span>Some ECG findings must ultimately be confirmed by an electrophysiology study before we can know for sure what is going on.</p><p class="MsoNormal">For those of us who are “ECG nerds”, it can be fun to debate our opinions and even more fun to hear from wiser, more advanced practitioners about their interpretations.</p><p class="MsoNormal">My belief, as a clinical instructor, is that we must teach strategies for treating the patient who has a “controversial” ECG that take into account the level of the practitioner, the care setting, and the patient’s hemodynamic status.<span style="mso-spacerun: yes;">  </span>In some settings, it might be absolutely forbidden for a first-responder to cardiovert atrial fibrillation, for example.<span style="mso-spacerun: yes;">  </span>But atrial fib is routinely cardioverted under controlled conditions in hospitals.<span style="mso-spacerun: yes;">  </span>The general rule followed by emergency providers that “all wide-complex tachycardias are v tach until proven otherwise” has no doubt prevented deaths in situations where care providers did not agree on the origin of the tachycardia.</p><p class="MsoNormal"><strong><span style="color: #00b050;">The ECG: <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></span></strong>We do not have much patient information to go with this ECG, just that it is from a 71-year-old woman who developed severe hypotension and lost consciousness, but was revived with transcutaneous pacing.<span style="mso-spacerun: yes;">   </span>Here is what we do know about this ECG:</p><p class="MsoListParagraphCxSpFirst" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">        </span></span></span><!--[endif]-->There are regular P waves, at a rate of about 39 bpm (sinus bradycardia).</p></div></div></div> Thu, 04 Jun 2020 20:24:18 +0000 Dawn 785 at https://www.ecgguru.com Previous Anterior Wall M.I. https://www.ecgguru.com/ecg/previous-anterior-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/previous-anterior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB119%20First%20deg%20AVB%20old%20AWMI.jpg" width="1800" height="1274" 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"> </p><p class="MsoNormal">If you are an instructor, or a fairly new student, you don’t always need to see “challenging” ECGs. But, you may not want to see “standard” ECGs from an arrhythmia generator, either.<span style="mso-spacerun: yes;">  </span>Every ECG contains subtle and not, so subtle characteristics of the person it belongs to.<span style="mso-spacerun: yes;">  </span>Take a minute to look at this ECG before reading the discussion, and ask yourself what you might surmise about the patient.</p><p class="MsoNormal"><strong><span style="color: #00b050;">The Patient: </span></strong>We don’t know much about the actual patient this ECG came from.<span style="mso-spacerun: yes;">  </span>What we do know is that he is an elderly man with a history of heart disease who was hospitalized sometime in the past with an acute M.I.<span style="mso-spacerun: yes;">  </span>He is now on beta blocker medication and is on a diet, as he is approaching the “morbidly obese” classification.<span style="mso-spacerun: yes;">  </span>He is now in the ER with shortness of breath and mild chest pain.<span style="mso-spacerun: yes;">  </span>What does his ECG tell us?</p></div></div></div> Sun, 08 Mar 2020 02:52:42 +0000 Dawn 782 at https://www.ecgguru.com Wide QRS Complex With First-degree AV Block https://www.ecgguru.com/ecg/wide-qrs-complex-first-degree-av-block <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-qrs-complex-first-degree-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IVCD_0.jpg" width="1800" height="983" 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 style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">The Patient:<span style="mso-spacerun: yes;">  </span></span></strong>This ECG was taken from a 73-year-old man with a history of heart failure with preserved ejection fraction, severe left ventricular hypertrophy, Type II diabetes, and stage 4 chronic kidney disease.<span style="mso-spacerun: yes;">  </span>He also suffered deep vein thrombosis and is on anticoagulation.<span style="mso-spacerun: yes;">  </span>He has a recent diagnosis of IgA myeloma.<span style="mso-spacerun: yes;">  </span>He presented with a complaint of nausea and vomiting and was found to have a worsening of acute kidney infection.<span style="mso-spacerun: yes;">  </span>There was suspicion of renal and cardiac amyloidosis, but the patient refused biopsy to confirm this.<span style="mso-spacerun: yes;">  </span>He was started on chemotherapy for multiple myeloma and will be followed as an outpatient.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">The ECG:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">  </span></span>The rhythm is <strong style="mso-bidi-font-weight: normal;">sinus</strong> at around 60 bpm, although the rate varies a little at the beginning of the strip.<span style="mso-spacerun: yes;">  </span>The QRS complex is wide at .12 seconds, or 120 ms., representing <strong style="mso-bidi-font-weight: normal;">interventricular conduction</strong> <strong style="mso-bidi-font-weight: normal;">delay (IVCD)</strong>.<span style="mso-spacerun: yes;">  </span>The PR interval is .32 seconds, or 320 ms. This constitutes <strong style="mso-bidi-font-weight: normal;">first-degree AV block.<span style="mso-spacerun: yes;">  </span></strong>There is left axis deviation in the frontal plane and poor R wave progression in the horizontal plane.</p></div></div></div> Fri, 07 Jun 2019 20:48:29 +0000 Dawn 769 at https://www.ecgguru.com Right Bundle Branch Block With Probable Previous M.I. https://www.ecgguru.com/ecg/right-bundle-branch-block-probable-previous-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/right-bundle-branch-block-probable-previous-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/RBLAH104.jpg" width="1800" height="1347" 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><span style="color: #00b050;">This ECG </span></strong>was obtained from an 87-year-old man with chest discomfort.  We have no other clinical information.</p><p class="MsoNormal"><strong><span style="color: #00b050;">ECG Interpretation   </span></strong>The rhythm is regular and fast, with P waves, at 95 beats per minute. So, it is <strong>normal sinus rhythm</strong>, but the rate is probably not “normal” for this patient.  The P waves are small, and difficult to see.  We suggest Lead I to best view the P waves in this example. This is a good opportunity to teach the value of evaluating rhythm strips in more than one simultaneous lead, as subtle features may not show up well in all leads.  There is a <strong>first-degree AV block</strong>, with a PR interval of 232 ms.</p><p class="MsoNormal">We see the <strong>right bundle branch block (RBBB) pattern</strong>: rSR’ in the right precordial leads (with a tiny q wave in V1, which is not typical of  RBBB).  The QRS is wide at 148 ms (.148 seconds).  The R prime (R’) represents the right ventricle depolarizing slightly after the left ventricle.  This terminal delay widens the QRS without affecting the depolarization or contraction of the left ventricle.  This delay can be seen in every lead, but is especially easy to see in Leads I and V<sub>6</sub>, where there is a wide little s wave.  It is normal for the T waves to be in a direction opposite that of the terminal wave (inverted in Leads V<sub>1</sub> and III, for example.)</p><p class="MsoNormal"><strong>There is left axis deviation.</strong>  The causes of LAD are many.  It is not unusual for people with RBBB to also have a left anterior hemiblock (LAH), also called left anterior fascicular block.  The left anterior fascicle has the same blood supply as the right bundle branch.   LAH causes a frontal plane axis shift – instead of Lead II having the tallest QRS of the limb leads, Leads I and aVL will be the tallest upright QRS complexes of the six limb leads.  Lead II will be very small, or flat, or negative. However, the probability of <strong>pathological Q waves</strong> in the inferior leads offers a more likely explanation for the leftward axis shift.  The M.I. that would have caused these Q waves is old, as there are no acute ST changes.  It would, of course, help to know this patient’s history.</p><p class="MsoNormal">Right bundle branch block can make evaluating for ST segment elevation a bit tricky.  Occasionally, the terminal delay – especially in Leads III and aVF – can be mistaken for ST elevation.  The J points in this ECG all appear to be at the baseline, with no overt STEMI.</p><p class="MsoNormal"> </p></div></div></div> Sat, 08 Sep 2018 20:35:12 +0000 Dawn 760 at https://www.ecgguru.com Non-Sustained Ventricular Tachycardia https://www.ecgguru.com/ecg/non-sustained-ventricular-tachycardia-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/non-sustained-ventricular-tachycardia-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/MR119%20NonSust%20VT.jpg" width="1800" height="951" alt="" /></a></div><div class="field-item odd"><a href="/ecg/non-sustained-ventricular-tachycardia-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/MR119%20NonSust%20VT%20Marked%20Up_0.jpg" width="1800" height="951" 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 obtained from a 45-year-old man who was experiencing palpitations and lightheadedness, which he originally attributed to anxiety. There are short, but frequent periods of ventricular tachycardia, which are self-limiting. &nbsp;This is called "NON-SUSTAINED VENTRICULAR TACHYCARDIA". &nbsp;The underlying rhythm is sinus, with a remarkably long PR interval, and at least one episode of failure of the P wave to conduct, making "second-degree AV block, Type II" a possibility. It is difficult to thoroughly evaluate the underlying rhythm because it is not seen very often in this ECG. The rate of the underlying P waves is about 67 bpm. &nbsp;The PR interval is .40 seconds (400 ms). &nbsp;The "normal" QRS complexes are slightly widened, at about .10 sec (100 ms), which is typical of Type II AVB. &nbsp;The ventricular QRS complexes are wide at .16 sec. (160 ms)</p><p>To assist you in using this tracing for teaching, we have also supplied a "marked up" version. &nbsp;The P waves, both visible and hidden, are marked with red lines. The PR intervals are shown in the Lead V1 rhythm strip in green. &nbsp;And the QRS complexes are numbered. &nbsp;QRS complexes numbered 2, 3, 6, and 12 are sinus. The P wave AFTER QRS #5 is non-conducted.</p><p>To review the differentiation of ventricular tachycardia from supraventricular tachycardia with aberrant conduction, go <a title="Dx WCT" href="http://ecgguru.com/expert-review/what-are-criteria-determining-wide-complex-tachycardia-v-tach">HERE</a>.</p></div></div></div> Sat, 04 Jun 2016 20:02:27 +0000 Dawn 700 at https://www.ecgguru.com Hyperkalemia https://www.ecgguru.com/ecg/hyperkalemia-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/hyperkalemia-1"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Elect%20101%20Hyperkalemia%20%20K%207.4.jpg" width="1800" height="850" 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: 19.5px; clear: left;">This ECG was obtained from a patient who had a serum potassium level of 7.4 mEq/L.  It shows some of the earliest ECG signs of hyperkalemia.  There are tall, sharply-peaked T waves in many leads.  The P waves have not yet widened and lost amplitude, but they will soon flatten out and disappear.  At this level of hyperkalemia, we can expect to see conduction disturbances (first-degree AV block in this case) and bradycardia (not yet). It is a bit surprising that the QRS complexes have not yet widened at this serum K level.    <strong style="outline: 0px; font-family: inherit; font-size: inherit; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: inherit;">Caution:  hyperkalemia can progress and become life-threatening very quickly.</strong></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: 19.5px; clear: left;">Potassium is primarily an intracellular electrolyte.  It is necessary for proper electrical functioning of the heart.  Extracellular  serum potassium can rise due to renal failure, or taking potassium supplements, potassium-sparing diuretics, or ACE inhibitors.  Occasionally, serum K levels may be artificially elevated by drawing the blood with too much syringe pressure, or using too small a needle, as the red blood cells can be damaged and release intracellular K into the serum.</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: 19.5px; clear: left;">ECG signs may vary among people with hyperkalemia, but in general:</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: 19.5px; clear: left;"><strong style="outline: 0px; font-family: inherit; font-size: inherit; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: inherit;">Serum K levels of 5.5 mEq/L or greater </strong>can cause repolarization abnormalities like tall, peaked T waves.</p></div></div></div> Sun, 23 Aug 2015 20:06:34 +0000 Dawn 659 at https://www.ecgguru.com ECG Basics: Sinus Bradycardia With First-degree AV Block https://www.ecgguru.com/ecg/ecg-basics-sinus-bradycardia-first-degree-av-block-0 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics-sinus-bradycardia-first-degree-av-block-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/126%20Sinus%20brady%20c%201st%20degree%20AVB.jpg" width="1800" height="260" 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 a nice teaching strip of a slowing sinus bradycardia that began around 40 bpm, and is slowing. &nbsp;It is a good example of how the sinus node slows down - there is no abrupt change of rates, rather a change with each R-to-R interval. &nbsp;There is also a first-degree AV block, reflecting slowing of conduction in the AV node. &nbsp;The PR interval is slightly variable at .28 sec. to about .32 sec. &nbsp;This is a good strip to begin talking about treatment of bradycardias with beginner students, as there is no second- or third-degee AVB, but the patient is very likely to be symptomatic now, or very soon. &nbsp;Atropine would probably improve this rate in a symptomatic patient, but if there is time, a 12-Lead would be a good idea to rule out acute M.I. &nbsp;Inadvertently raising the rate too much in the injured heart can lead to pump failure, while leaving the patient poorly-perfused in a bradycardia will starve the heart. &nbsp;A transthoracic or temporary IV pacemaker might be a better choice for some patients because of our ability to choose the rate.</p></div></div></div> Fri, 10 Jan 2014 21:52:59 +0000 Dawn 540 at https://www.ecgguru.com Left Ventricular Hypertrophy With Strain https://www.ecgguru.com/ecg/left-ventricular-hypertrophy-strain-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/left-ventricular-hypertrophy-strain-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LVH%20105_0.jpg" width="1800" height="891" 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 man with left ventricular hypertrophy.  LVH causes taller-than-normal QRS complexes in leads oriented toward the left side of the heart, such as Leads I, II, aVL, V4, V5, and V6.  Leads on the opposite side, such as V1, V2, and V3, will have deeper-than-normal S waves.  A commonly-used criteria for determination of LVH is the <span style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;"> </span><strong style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;">Sokolow-Lyon index:    </strong><strong style="font-family: sans-serif; line-height: 10.838068008422852px;"><span style="font-size: xx-small;"> </span></strong><span style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;">S in V</span><sub style="font-family: sans-serif; line-height: 1em;">1</sub><span style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;"> </span><span style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;">+ R in V</span><sub style="font-family: sans-serif; line-height: 1em;">5</sub><span style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;"> </span><span style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;">or V</span><sub style="font-family: sans-serif; line-height: 1em;">6</sub><span style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;"> </span><span style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;">(whichever is larger) ≥ 35 mm (≥ 7 large squares);  and  </span><span style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;">R in aVL ≥ 11 mm.  There is no perfect ECG criteria for determining LVH. The most accurate way to evaluate the size and thickness of the chambers of the heart is echocardiogram (ultrasound).  Frequently, there is left axis deviation, especially if the hypertrophy is confined to the left ventricle.</span></p><p><span style="font-family: sans-serif; font-size: 13px; line-height: 19.1875px;">The left ventricle can be enlarged for many reasons, some worse than others.  Athletes naturally enlarge the heart, as they work the muscle.  Pathological causes for LVH can include anything that strains the heart as it pushes against increased afterload, such as hypertension and aortic stenosis, and diseases of the myocardium, such as cardiac myopathies.</span></p></div></div></div> Thu, 12 Dec 2013 16:38:35 +0000 Dawn 524 at https://www.ecgguru.com ECG BASICS: Sinus Bradycardia With First-degree AV Block https://www.ecgguru.com/ecg/ecg-basics-sinus-bradycardia-first-degree-av-block <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics-sinus-bradycardia-first-degree-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/100%20SB%20with%201st%20degree%20AVB.jpg" width="1800" height="216" 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>TODAY, we are starting a new feature on the ECG GURU.&nbsp; ECG BASICS will provide rhythm strips and 12-leads for your beginner or refresher students.&nbsp; It can be discouraging to the entry-level student to see only intermediate or advanced material and not understand it.&nbsp; We must remember to start at the most elementary concepts, and then build on them, just as we do with any other subject.&nbsp; Even more advanced students sometimes benefit from a return to the "basics".&nbsp; In this weekly feature, you will find downloadable content that is, like all ECG Guru content, FREE for use in an educational context.&nbsp; Please let us know in the "Comments" section below what ECGs, rhythm strips, or illustrations you would like to see featured in this new area.</p><p>&nbsp;</p><p>Today's strip:&nbsp; Sinus bradycardia with first-degree AV block.&nbsp; The rate is in the 30's and slowing, and the PR interval is .26 seconds.</p></div></div></div> Sun, 21 Apr 2013 15:40:49 +0000 Dawn 435 at https://www.ecgguru.com Sinus Bradycardia With First-Degree AV Block and Left Anterior Fascicular Block https://www.ecgguru.com/ecg/sinus-bradycardia-first-degree-av-block-and-left-anterior-fascicular-block <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/sinus-bradycardia-first-degree-av-block-and-left-anterior-fascicular-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/MRLAH100.jpg" width="1400" height="745" 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 a good ECG for demonstrating sinus brady and first-degree AV block. It shows the sinus node in the process of slowing down. For your more advanced students, there is left axis deviation due to left anterior fascicular block (left anterior hemiblock). The ST segments are flat, suggesting coronary artery disease. The fourth (bottom) channel is a good rhythm strip. Just crop the image. Please refer to Dr. Grauer's interesting post on teaching hemiblocks on our <a href="http://ekgguru.com/members/ask-the-expert">Ask The Expert </a>page.</p></div></div></div> Sun, 10 Mar 2013 07:13:52 +0000 Dawn 128 at https://www.ecgguru.com Inferior Wall M.I. With Sinus Bradycardia and First-degree AV Block https://www.ecgguru.com/ecg/inferior-wall-mi-sinus-bradycardia-and-first-degree-av-block <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/inferior-wall-mi-sinus-bradycardia-and-first-degree-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW101_0.jpg" width="1800" height="867" 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>Inferior wall MI: ST elevation in II, III, and aVF. Reciprocal ST depressions. Sinus bradycardia and first-degree AV block suggests sinus node and AV node ischemia. This is a good "classic" inferior wall M.I. It is good for teaching inferior-posterior injury, and the effects of RCA occlusion on the sinus and AV nodes.&nbsp;The low voltage in the limb leads may also be due to acute M.I., but in this case, we do not know the patient's body size.</p> <p>&nbsp;</p> </div></div></div> Mon, 13 Aug 2012 16:51:01 +0000 Dawn 57 at https://www.ecgguru.com Jason’s blog: ECG Challenge of the Week for June 24 – July 1, 2012. Pinpoint the primary disturbance. https://www.ecgguru.com/blog/jason%E2%80%99s-blog-ecg-challenge-week-june-24-%E2%80%93-july-1-2012-pinpoint-primary-disturbance <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/jason%E2%80%99s-blog-ecg-challenge-week-june-24-%E2%80%93-july-1-2012-pinpoint-primary-disturbance"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/ECG%20of%20the%20Week%201c%20answer.png" width="765" height="499" alt="" /></a></div><div class="field-item odd"><a href="/blog/jason%E2%80%99s-blog-ecg-challenge-week-june-24-%E2%80%93-july-1-2012-pinpoint-primary-disturbance"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/ECG%20of%20the%20Week%201c%20F-U_0.png" width="765" height="499" 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><span style="font-size: 12pt; line-height: 115%; font-family: times new roman,times;">This patient was seen by his primary care provider (PCP) on an outpatient basis.  The PCP decided to send her patient over to me to perform a routine ECG and establish a baseline, hince the computer's statement below of <em>"No previous ECGs available"</em>.  I printed out the above 12-lead ECG and became slightly concerned with the rhythm I was seeing.  Consequently, I also recorded six full pages of continuous rhythm (<em>not shown here</em>).  I don’t ordinarily resort to doing this </span></p></div></div></div> Sun, 24 Jun 2012 04:00:52 +0000 jer5150 238 at https://www.ecgguru.com