ECG Guru - Instructor Resources - ST changes https://www.ecgguru.com/ecg/st-changes en Marked Bradycardia With Bifascicular Block https://www.ecgguru.com/ecg/marked-bradycardia-bifascicular-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/marked-bradycardia-bifascicular-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Junctional%20RBBB%20LPH.jpg" width="1800" height="1257" 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="font-size: 12.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp; </span></span><span style="font-size: 12.0pt; line-height: 107%;">This ECG was taken from an elderly woman. Unfortunately, we do not know any details about the case.<span style="mso-spacerun: yes;">&nbsp; </span>That acknowledged, there are many interesting aspects to this ECG.</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The ECG:</span></strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 12.0pt; line-height: 107%;">The first thing we notice is the severe <strong>bradycardia</strong> – almost certain to be symptomatic.<span style="mso-spacerun: yes;">&nbsp; </span>The rate is 32 bpm and the rhythm is regular.<span style="mso-spacerun: yes;">&nbsp; </span>There are no P waves.<span style="mso-spacerun: yes;">&nbsp; </span>This is a <strong>junctional rhythm</strong>, slightly slower than expected from junctional escape.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The QRS shows the presence of <strong>right bundle branch block</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>Each QRS on the ECG starts as a narrow complex, but then adds an “extra” wave onto the end – the delay caused by the right ventricle depolarizing late.<span style="mso-spacerun: yes;">&nbsp; </span>The terminal delay is very noticeable in V1 as an R’ wave, and in Leads I and V6 as a small, wide s wave.<span style="mso-spacerun: yes;">&nbsp; </span>There is right axis deviation, so the diagnosis of <strong>bifascicular block</strong> (RBBB and left posterior fascicular block) can be made.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">V2 through V6 show <strong>fragmentation of the QRS </strong>complexes and a loss of voltage and R wave progression.<span style="mso-spacerun: yes;">&nbsp; </span>This points to anterior wall M.I. We can’t know the age of the M.I. without clinical correlation, but the ST segments in those leads are very <strong>flat,</strong> with uniformly symmetrical <strong>inverted T waves</strong> all the way to V6.<span style="mso-spacerun: yes;">&nbsp; </span>All of these signs indicate recent injury.<span style="mso-spacerun: yes;">&nbsp; </span>An anterior M.I. can cause the bifascicular block we are seeing, since the bundle branches begin in the septum.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Our patient has a host of <strong>conduction system problems</strong>:<span style="mso-spacerun: yes;">&nbsp; </span>there is no sign of sinus node activity, the junctional escape rhythm is slow even for the junction, there is a right bundle branch block, and the left posterior fascicle is blocked. <span style="mso-spacerun: yes;">&nbsp;</span>Many diseases can cause these conduction system failures, including M.I. as well as diseases causing inflammation and fibrosis of tissues. Finding the underlying cause(s) of all these abnormalities is very important, but the FIRST consideration should be protecting perfusion by insuring an adequate rate.<span style="mso-spacerun: yes;">&nbsp; </span>This patient is certainly a candidate for a pacemaker, with her bradycardia and the fact that she is living with only one main fascicle in her bundle branches (the anterior-superior fascicle).</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/797/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 Marked Bradycardia With Bifascicular Block 1/5</option><option value="40">Give Marked Bradycardia With Bifascicular Block 2/5</option><option value="60">Give Marked Bradycardia With Bifascicular Block 3/5</option><option value="80" selected="selected">Give Marked Bradycardia With Bifascicular Block 4/5</option><option value="100">Give Marked Bradycardia With Bifascicular Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.4</span></span> <span class="total-votes">(<span >78</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-c9KiudSz1iAvPSyxmFc4AYRsAO9RZGJ8SaRlR6FKz0M" /> <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/bifascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bifascicular block</a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item even"><a href="/ecg/left-posterior-fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior fascicular block</a></div><div class="field-item odd"><a href="/ecg/left-posterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior hemiblock</a></div><div class="field-item even"><a href="/ecg/junctional-rhythm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Junctional rhythm</a></div><div class="field-item odd"><a href="/ecg/qrs-fragmentation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">QRS fragmentation</a></div><div class="field-item even"><a href="/ecg/st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST changes</a></div><div class="field-item odd"><a href="/ecg/anterior-wall-mi-5" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior wall M.I.</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%2Fmarked-bradycardia-bifascicular-block&amp;title=Marked%20Bradycardia%20With%20Bifascicular%20Block"><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> Sun, 10 Jul 2022 20:08:14 +0000 Dawn 817 at https://www.ecgguru.com https://www.ecgguru.com/ecg/marked-bradycardia-bifascicular-block#comments Right Bundle Branch Block and More https://www.ecgguru.com/ecg/right-bundle-branch-block-and-more <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-and-more"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/SR%20w%20PACs%2011.43.jpg" width="1800" height="663" alt="" /></a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-and-more"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Leads%2013%2C%2014%2C%2015_0.jpg" width="1800" height="689" 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="font-size: 12.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-tab-count: 1;">&nbsp;&nbsp;&nbsp; </span>These tracings are taken from a 75-year-old man who became weak while playing golf on a very hot day.<span style="mso-spacerun: yes;">&nbsp; </span>He was pale and diaphoretic.<span style="mso-spacerun: yes;">&nbsp; </span>He was hypotensive, but we do not know his BP reading. He denies chest pain or discomfort. The patient reported a history of lung cancer and hypertension. We have no other history, and unfortunately, no follow-up information.</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">ECG Number 1: </span></strong><strong><span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-tab-count: 1;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></strong><span style="font-size: 12.0pt; line-height: 107%;">The first ECG shows the standard 12 leads.<span style="mso-spacerun: yes;">&nbsp; </span>The rhythm is sinus with frequent appearances of PAC couplets.<span style="mso-spacerun: yes;">&nbsp; </span>The sinus rate varies slightly from about 76 bpm to 68 bpm, tending to slow a bit after the premature atrial contractions.<span style="mso-spacerun: yes;">&nbsp; </span>There is a right bundle branch block, and the QRS duration is about .12 seconds (120 ms). The PR interval is slightly log at 223 ms.<span style="mso-spacerun: yes;">&nbsp; </span>We do not know what medications the patient is on, and we do not have an older ECG for comparison.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">There are some interesting, if subtle, changes worth mentioning.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS complexes in most leads are fragmented.<span style="mso-spacerun: yes;">&nbsp; </span>That is, they have notching in the terminal S or R waves that is not due to the bundle branch block. This can be a sign of scarring, and can also be considered an equivalent to a pathological Q wave.<span style="mso-spacerun: yes;">&nbsp; </span>Speaking of pathological Q waves, they are seen in the inferior leads, II, III, and aVF.<span style="mso-spacerun: yes;">&nbsp; </span>There are also prominent, though not large Q waves in V4 through V6, leads which normally do not have them. All this points to scarring and possibly long-term coronary artery disease, with possible old M.I.<span style="mso-spacerun: yes;">&nbsp; </span>In addition, the ST segments are not entirely normal.<span style="mso-spacerun: yes;">&nbsp; </span>There is ST depression in the inferior and low lateral leads, a little ST elevation in aVL.<span style="mso-spacerun: yes;">&nbsp; </span>Also, the SHAPES of the ST segments tend to be straight throughout the ECG, instead of the usual curved (concave up) appearance. </span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">ECG Number 2:<span style="mso-tab-count: 1;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">The second ECG was obtained with three additional leads, to search for ST elevation that might have been missed by the standard 12 leads.<span style="mso-spacerun: yes;">&nbsp; </span>V4, Right has been added in place of V4.<span style="mso-spacerun: yes;">&nbsp; </span>V8 and V9 have been added to the V5 and V6 positions on the print out.<span style="mso-spacerun: yes;">&nbsp; </span>V4R shows us a pathological Q wave and fragmentation.<span style="mso-spacerun: yes;">&nbsp; </span>The posterior leads do, too, and the ST segments are very flat and slightly elevated.</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">Conclusion: <span style="mso-spacerun: yes;">&nbsp;</span></span></strong><span style="font-size: 12.0pt; line-height: 107%;">Without further evaluation of the patient, and comparison with previous ECGs, it would be very difficult to assign significance to these changes.<span style="mso-spacerun: yes;">&nbsp; </span>Because of his symptoms, he was transported by EMS to a hospital.<span style="mso-spacerun: yes;">&nbsp; </span>For teachers, this is a good example of PAC couplets for your beginner students, and a chance to discuss QRS fragmentation, pathological Q waves, and ST segment shape with your more advanced students.<span style="mso-spacerun: yes;">&nbsp; </span>Also, the value of additional leads to rule out ST elevation M.I. should be emphasized.</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/797/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 Right Bundle Branch Block and More 1/5</option><option value="40">Give Right Bundle Branch Block and More 2/5</option><option value="60">Give Right Bundle Branch Block and More 3/5</option><option value="80" selected="selected">Give Right Bundle Branch Block and More 4/5</option><option value="100">Give Right Bundle Branch Block and More 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.4</span></span> <span class="total-votes">(<span >43</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-vGhu3G_iL7WuUNH57u0zGD94-5UGUXM47JtL_j0QF_0" /> <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/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item odd"><a href="/ecg/rbbb" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">RBBB</a></div><div class="field-item even"><a href="/ecg/left-posterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior hemiblock</a></div><div class="field-item odd"><a href="/ecg/qrs-fragmentation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">QRS fragmentation</a></div><div class="field-item even"><a href="/ecg/pacs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PACs</a></div><div class="field-item odd"><a href="/ecg/couplets" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Couplets</a></div><div class="field-item even"><a href="/ecg/st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST changes</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%2Fright-bundle-branch-block-and-more&amp;title=%20Right%20Bundle%20Branch%20Block%20and%20More"><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 Aug 2020 21:33:52 +0000 Dawn 788 at https://www.ecgguru.com https://www.ecgguru.com/ecg/right-bundle-branch-block-and-more#comments