Triage EKG—Unit 7, Case 28

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Triage EKG—Unit 7, Case 28

Courtesy of Edward Burns of Life in the Fast Lane

Unit 7, Case 28 - Bifascicular Block with 1st Degree AV Block

What is your interpretaꢀon of the EKG?

History/Clinical Picture— elderly woman with CHF who presents with syncope Rate— 70 Rhythm— Sinus rhythm Axis— leﬅ axis deviaꢀon P Waves— present Q, R, S Waves— no clear pathologic q waves, S-waves inferiorly and laterally, early R-wave progression T Waves— inversions inveriorly U Waves— not present PR Interval— consistently prolonged at 220 ms consistent with 1st Degree AV Block. No progressive prolongaꢀon that would be consistent with 2nd Degree Type I or intermiꢁent dropped beats that would be consistent with 2nd Degree Type II QRS Width— prolonged at just over 120 ms with RBBB and LAFB

RBBB: RSR’ in V1 and QRS > 120ms
LAFB: 1. Leﬅ axis deviaꢀon

2. Small q waves with large R waves (“qR complexes”) in I and aVL

3. Small r waves with large S waves (“rS complexes”) in II, III, and aVF

4. Normal or slightly prolonged QRS duraꢀon (80-110 ms).

ST Segment— no marked elevaꢀon or depression QT Interval— normal

Diagnosis: Bifascicular block (RBBB + LAFB) with ﬁrst degree AV block

Management: This EKG shows severe disease of the interventricular conducꢀon system. A right bundle branch block with a leﬅ anterior fascicular block (or leﬅ posterior fascicular block) in the presence of a 1st degree AV nodal block is someꢀmes erroneously called a “trifascicular block”. Conducꢀon between the atria and the ventricles is reliant on the remaining fascicle, in this case the leﬅ posterior fascicle. The long PR suggests that this remaining fascicle is also diseased, and thus the paꢀent is at risk of progressing to complete heart block. While a bifascicular block with concurrent 1st degree AV block is not an indicaꢀon for a pacemaker on its own, paꢀents with this rhythm who present with syncope should be admiꢁed and evaluated for evidence of intermiꢁent third degree heart block, which would necessitate pacemaker placement.

Resource Links: Life in the Fast Lane — great overview

Dr. Steve Smith’s Blog – good case

Created by Duncan Wilson, MD Edited by Nick Hartman, MD & Kristen Grabow Moore, MD

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Definition of Terms Related to Cardiac Rhythm*

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View Pdf Copy of Original Document

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Radiofrequency Catheter Ablation for Treatment of Bundle Branch Reentrant Ventricular Tachycardia : Results and Long-Term Follow-Up TODD J

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MODULEMODULE 11 RhythmRhythm BasicsBasics ModuleModule 1:1: RhythmRhythm BBaasicssics OverviewOverview •• TheThe ConductionConduction SystemSystem –– ImpulseImpulse FormationFormation –– ImpulseImpulse ConductionConduction –– PropertiesProperties ofof CardiacCardiac FunctionFunction –– 55 PhasesPhases ofof ActionAction PotentialPotential •• RhythmRhythm DisordersDisorders –– MechanisMechanismsms –– ArrhythmArrhythmiaia RecognitionRecognition •• CausesCauses ofof RhythmRhythm DisordersDisorders ModuleModule 1:1: RhythmRhythm BBaasicssics ObjectivesObjectives •• IdentifyIdentify thethe componentscomponents thatthat makemake upup thethe electricalelectrical pathwaypathway knownknown asas thethe conductionconduction systemsystem •• StateState thethe 55 phasesphases ofof actionaction potentialpotential •• DescribeDescribe thethe mechanismsmechanisms causingcausing rhythmrhythm disordersdisorders •• IdIdentifyentify rhythmrhythm ddiisorderssorders onon anan EKGEKG THETHE CONDUCTIONCONDUCTION SYSTEMSYSTEM HeartHeart BeBeatat AnatomyAnatomy SINUS NODE • The Heart’s ‘Natural Pacemaker’ Sinus Node (SA Node) - 60-100 BPM at rest HeartHeart BeBeatat AnatomyAnatomy AV NODE • Receives impulse from Sinus Node SA Node (SA Node) • Delivers impulse to the His- Purkinje System Atrioventricular Node (AV Node) • 40-60 BPM if SA Node fails to deliver an impulse HeartHeart BeBeatat AnatomyAnatomy BUNDLE OF HIS •Begins conduction to Sinus Node the Ventricles (SA Node) • AV Junctional Tissue: 40-60 BPM Atrioventricular Node (AV Node) Bundle of His HeartHeart
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Bradycardia and Heart Block The conduc3on system SA node (natural pacemaker) AV node (junction box) Left bundle branch posterior fascicle Left bundle branch anterior fascicle Right bundle branch The normal ECG Bradycardia • The conduc3on system can fail at any point • Bradycardia per se is not a bad thing • Bradycardia without symptoms is usually not an issue, except in select cases The conduc4on system – SA node SA node (natural pacemaker) Sinus Bradycardia Sinus Bradycardia – a problem? • Physically ﬁt people have heart rates in the 50s • Athletes can have heart rates as low as 25 without a problem • If this is an 80 yr old lady, chances are this is sinus node dysfuncon • If she has lethargy, exercise incapacity, falls or blackouts, refer for consideraon of pacing Atrial Pacemakers • Atrial pacemakers can restore exercise capacity • Have not been shown to improve mortality, only morbidity What is happening with the rhythm? Sinus arrhythmia: Sinus arrhythmia • In itself not an issue • Usually mediated by vagal tone • Common in athletes What is unusual about this rhythm strip? Low atrial rhythm – usually benign Describe the rhythm strip Junconal ectopics (no p waves visible with the ectopics despite ‘room’ to see them) Profoundly hypothyroid paent Junconal bradycardia The conducon system AV node (junction box) Left bundle branch anterior fascicle The AV node • If problems occur within the AV node, they can form one of the three types of HB • First degree (conducts every beat) • Second degree (conducts some beats) • Third degree heart block