ECG Guru - Instructor Resources - Escape-capture bigeminy https://www.ecgguru.com/ecg/escape-capture-bigeminy en AV Block of Undetermined Type https://www.ecgguru.com/ecg/av-block-undetermined-type <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/av-block-undetermined-type"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/164%20High%20grade%20AVB.jpg" width="1800" height="265" alt="" /></a></div><div class="field-item odd"><a href="/ecg/av-block-undetermined-type"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/164%20High%20grade%20AVB%20Marked%20up.jpg" width="1800" height="265" 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 strip was obtained from a woman who presented to her doctor’s office with hypertension. While there is some artifact in the baseline, it is possible to determine the presence of P waves, thanks in part to having two leads to assess.&nbsp; We have provided an unmarked version of the strip for you to use, and also a marked version for the sake of this discussion.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The underlying rhythm</span><span style="font-size: 12pt; line-height: 107%;"> is sinus bradycardia, at about 60 bpm, but with some slight variation in the P to P intervals (about 920 ms to 1040 ms). Because of the artifact, it is difficult to determine the exact P to P intervals, and the exact morphology of the P waves. So, we can’t say for sure that the P waves are all alike.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The AV block </span><span style="font-size: 12.0pt; line-height: 107%;">occurs at a 3:1 ratio.&nbsp; That is, for every three P waves, one is conducted and produces a QRS complex.&nbsp; When the P waves are not conducted, an escape rhythm occurs.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The escape rhythm </span><span style="font-size: 12.0pt; line-height: 107%;">occurs at an escape interval of about 1720 ms.&nbsp; In other words, when a QRS does not occur by that time, the escape beat is produced.&nbsp; It appears to be from the AV junction, in spite of the slow rate, because the escape QRSs look like the sinus conducted QRSs.&nbsp; Both sinus and junctional rhythms are conducted along the bundle branches and produce the same QRS morphology.&nbsp; The QRS complexes are approximately .08-.10 seconds wide.&nbsp; Note that QRS complexes numbered 3, 5, and 7 have a P wave fused to the beginning of the QRS, making the QRS look wide when it is not.&nbsp;&nbsp; A junctional escape rhythm results from AV block in the AV node, as the junction is the first available pacemaker below the AVN.</span><span style="font-size: 13.008px;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">This patient was scheduled for a treadmill stress test in her doctor’s office, which was cancelled. She had no cardiac symptoms at the time of the ECG, except the above-noted hypertension.&nbsp; Unexplained bradycardia, especially when accompanied by AV node blocks, should trigger an assessment for inferior wall M.I., since the inferior wall of the LV shares a blood supply with the SA and AV nodes in the majority of people.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Whether an AV block is "second-degree" or "third-degree" may not matter as much as WHERE the block is and what the resulting rate is.&nbsp; If the block is in the AV node, as opposed to the bundle branches or lower His bundle, the patient will have the benefit of a junctional escape rather than a ventricular escape rhythm. AV node level blocks tend to be temporary and reversible, while sub-Hisian blocks can be more permanent and more life-threatening. The rate, and the cardiac output, matter more to the patient than the "degree".&nbsp; Should the rate be so slow that the patient loses perfusion, a pacemaker may be required to increase it.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;"> Our thanks to Palm Beach Gardens Fire Rescue for donating this strip.</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/254/feed" method="post" id="fivestar-custom-widget" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--2" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give AV Block of Undetermined Type 1/5</option><option value="40">Give AV Block of Undetermined Type 2/5</option><option value="60" selected="selected">Give AV Block of Undetermined Type 3/5</option><option value="80">Give AV Block of Undetermined Type 4/5</option><option value="100">Give AV Block of Undetermined Type 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3</span></span> <span class="total-votes">(<span >7</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-bNqfRIu1bQ3_gkcNNTfQtxLijaKpr7TUZh54QkZqPA8" /> <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/high-grade-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">High-grade AV Block</a></div><div class="field-item odd"><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 even"><a href="/ecg/escape-capture-bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Escape-capture bigeminy</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></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fav-block-undetermined-type&amp;title=AV%20Block%20of%20Undetermined%20Type"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Wed, 22 Nov 2017 22:48:37 +0000 Dawn 741 at https://www.ecgguru.com https://www.ecgguru.com/ecg/av-block-undetermined-type#comments An Irregular Bradycardia https://www.ecgguru.com/ecg/irregular-bradycardia <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/irregular-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20Lead%209%2029%20am.jpg" width="1800" height="1078" alt="" /></a></div><div class="field-item odd"><a href="/ecg/irregular-bradycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12-Lead%2010%2042%20am.jpg" width="2008" height="1166" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal">Thank you to Alikuni Kllany from Toronto for donating these ECGs.&nbsp; They are from a 59-year-old man who has a history of hypertension and depression.&nbsp; Last year, he was on atenolol when he experienced a brief syncopal episode and bradycardia. He was taken off atenolol and started on amlodipine 5 mg.&nbsp; He also takes ramipril 10 mg, atorvastatin 40 mg, and tamsulosin .4 mg.&nbsp; He continues to have bradycardia and dizziness.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The first ECG shows grouped beating, with repetitive groups of two and three complexes.&nbsp; The P waves are very small, and hard to evaluate.&nbsp; The best place to see them is in the Lead II rhythm strip at the bottom.&nbsp; The rhythm strip is not run concurrently with the 12-Lead, making it even more difficult to evaluate P wave morphology.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The beats that begin the groups also END a pause.&nbsp; These are junctional escape beats.&nbsp; After the junctional escape beats, the PR intervals vary.&nbsp; This can be explained by <a href="http://ecgguru.com/expert-review/ask-expert-6">RP / PR reciprocity</a>, first described by Mobitz.&nbsp; He demonstrated that the RP interval can affect the next PR interval. Longer RP intervals (slower rate) cause PR shortening.&nbsp; Shorter RP intervals equal longer PR intervals.&nbsp; The P waves are so small, it is difficult to determine whether there is a P wave in the last T wave of each group, which would indicate non-conducted PACs.&nbsp; So, we are left with a sinus pause or sinus exit block (suggested by the timing of the first six beats.&nbsp; We have used red arrows to suggest where the sinus node probably fired.&nbsp; P waves indicate conduction, of course.&nbsp; Lack of P waves, the impulse failed to exit the sinus node.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">There are many mechanisms by which grouped beating can occur.&nbsp; Second-degree AVB, Type I (Wenckebach) comes to mind first.&nbsp; That rhythm in it’s pure form would have a regular sinus rhythm underlying it. &nbsp;&nbsp;Escape-capture bigeminy often occurs with slow rates and junctional escapes, but does not by itself cause “trigeminy”.&nbsp; Sick sinus syndrome can cause all types of chaos in the rhythm.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The second tracing shows a junctional escape rhythm with no obvious P waves (unsure because the P waves are small, and the 12-Lead is not concurrent with the rhythm strip at the bottom.)&nbsp; It is interesting that the rhythm strip shows four consecutive sinus beats at just under 60 bpm, and with P waves that look different from the P waves on the first ECG. &nbsp;This rate is similar, but not identical to, the sinus rate seen in the first ECG.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal">The bottom line for the clinician is that this patient, because he is symptomatic, requires a thorough workup.&nbsp; If the cause of the arrhythmias proves to be cardiac in origin, a pacemaker may be required.</p><p class="MsoNormal"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></p><p>&nbsp;</p><p class="MsoNormal">We welcome any and all discussions regarding this ECG, realizing that P waves are very difficult to evaluate, and that they are probably multi-focal.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/254/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 An Irregular Bradycardia 1/5</option><option value="40">Give An Irregular Bradycardia 2/5</option><option value="60">Give An Irregular Bradycardia 3/5</option><option value="80">Give An Irregular Bradycardia 4/5</option><option value="100" selected="selected">Give An Irregular Bradycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.3</span></span> <span class="total-votes">(<span >7</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-ZsS5WphYQ2ZLoBRbkLMdA6u528fbIH2TGSHiRIYjB_M" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/junctional-escape" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional escape</a></div><div class="field-item odd"><a href="/ecg/escape-capture-bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Escape-capture bigeminy</a></div><div class="field-item even"><a href="/ecg/r-p-p-r-reciprocity" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">R-P / P-R reciprocity</a></div><div class="field-item odd"><a href="/ecg/sinus-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus block</a></div><div class="field-item even"><a href="/ecg/sinus-pause" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus pause</a></div><div class="field-item odd"><a href="/ecg/bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bradycardia</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Firregular-bradycardia&amp;title=%20%20An%20Irregular%20Bradycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 31 Mar 2016 21:05:12 +0000 Dawn 693 at https://www.ecgguru.com https://www.ecgguru.com/ecg/irregular-bradycardia#comments Jason's Blog: ECG Challenge of the Week for Feb. 17th - 24th. https://www.ecgguru.com/blog/jasons-blog-ecg-challenge-week-feb-17th-24th <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/jasons-blog-ecg-challenge-week-feb-17th-24th"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/ECG%20of%20the%20Week%202e%20ladder_1.png" width="788" height="533" alt="" /></a></div><div class="field-item odd"><a href="/blog/jasons-blog-ecg-challenge-week-feb-17th-24th"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/ECG%20of%20the%20Week%202f%20supplimental%201.png" width="787" height="519" 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="text-decoration: underline;"><strong>Patient's clinical data:</strong></span>&nbsp; 81-year-old black man<br><br>The computer interpreted this ECG as:&nbsp; <br>Sinus bradycardia 1st degree AV block<br>ST abnormality, possible digitalis effect<br><span style="text-decoration: underline;">Abnormal ECG</span><br><span style="text-decoration: underline;">When compared with ECG of</span> <em>(expunged)</em><br><span style="text-decoration: underline;">PR interval has increased</span><br><span style="text-decoration: underline;">Vent rate has decreased by <strong>23 BPM</strong></span><br><br>DO YOU AGREE WITH THE COMPUTER?</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/254/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 Jason&amp;#039;s Blog: ECG Challenge of the Week for Feb. 17th - 24th. 1/5</option><option value="40">Give Jason&amp;#039;s Blog: ECG Challenge of the Week for Feb. 17th - 24th. 2/5</option><option value="60">Give Jason&amp;#039;s Blog: ECG Challenge of the Week for Feb. 17th - 24th. 3/5</option><option value="80">Give Jason&amp;#039;s Blog: ECG Challenge of the Week for Feb. 17th - 24th. 4/5</option><option value="100" selected="selected">Give Jason&amp;#039;s Blog: ECG Challenge of the Week for Feb. 17th - 24th. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.4</span></span> <span class="total-votes">(<span >5</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-13uh843lkq77-h-WbrShQSbaitcagYSe5FyVZnK3Etg" /> <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_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fblog%2Fjasons-blog-ecg-challenge-week-feb-17th-24th&amp;title=Jason%27s%20Blog%3A%20ECG%20Challenge%20of%20the%20Week%20for%20Feb.%2017th%20-%2024th."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 16 Feb 2013 20:29:08 +0000 jer5150 401 at https://www.ecgguru.com https://www.ecgguru.com/blog/jasons-blog-ecg-challenge-week-feb-17th-24th#comments Featured Case Study by Guru member Vince DiGiulio, EMT-CC. https://www.ecgguru.com/blog/featured-case-study-guru-member-vince-digiulio-emt-cc <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/featured-case-study-guru-member-vince-digiulio-emt-cc"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/1%20copy.png" width="765" height="671" alt="" /></a></div><div class="field-item odd"><a href="/blog/featured-case-study-guru-member-vince-digiulio-emt-cc"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/2%20copy.png" width="765" height="662" alt="" /></a></div><div class="field-item even"><a href="/blog/featured-case-study-guru-member-vince-digiulio-emt-cc"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/3%20copy.png" width="765" height="677" alt="" /></a></div><div class="field-item odd"><a href="/blog/featured-case-study-guru-member-vince-digiulio-emt-cc"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/4%20copy.png" width="765" height="686" 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>This week, in addition to my own blog, I'm going to feature a guest case study by Guru member Vince DiGiulio, EMT-CC.&nbsp; This past Monday, Vince messaged me (along with Dr. Ken Grauer) on Facebook and requested my input and opinion on these serial ECGs.&nbsp; With Vince's blessing, he gave me permission to use any of his original 12-lead ECGs here on the Guru.&nbsp; Of his 6 ECGs, I've decided to post 4 of them here.&nbsp; <span style="text-decoration: underline;"><strong><br><br>PATIENT'S CLINICAL DATA:</strong></span>&nbsp; 79-year-old female presents to triage with a chief complaint of intermittent dizziness for two weeks that has become rather constant over the past two days. Her pulse is noted to be 38/min and blood pressure 162/84 mmHg. She denies any chest pain or shortness of breath, and has not experienced any syncopal episodes.<br><br><span style="text-decoration: underline;"><strong>QUESTION:</strong></span><br>(1.)&nbsp; What's her rhythm?<br>(2.)&nbsp; What, if anything, did the computer interpret correctly?</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/254/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" selected="selected">Give Featured Case Study by Guru member Vince DiGiulio, EMT-CC. 1/5</option><option value="40">Give Featured Case Study by Guru member Vince DiGiulio, EMT-CC. 2/5</option><option value="60">Give Featured Case Study by Guru member Vince DiGiulio, EMT-CC. 3/5</option><option value="80">Give Featured Case Study by Guru member Vince DiGiulio, EMT-CC. 4/5</option><option value="100">Give Featured Case Study by Guru member Vince DiGiulio, EMT-CC. 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--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-zO2LgR-suCp5p0QH0jra9iiZ93I__yhxGsK1N4d3VGo" /> <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_4"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fblog%2Ffeatured-case-study-guru-member-vince-digiulio-emt-cc&amp;title=Featured%20Case%20Study%20by%20Guru%20member%20Vince%20DiGiulio%2C%20EMT-CC."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 22 Dec 2012 17:25:26 +0000 jer5150 382 at https://www.ecgguru.com https://www.ecgguru.com/blog/featured-case-study-guru-member-vince-digiulio-emt-cc#comments