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 Creative Commons License Unit 7, Case 28 - Bifascicular Block with 1st Degree AV Block What is your interpretation of the EKG? History/Clinical Picture— elderly woman with CHF who presents with syncope Rate— 70 Rhythm— Sinus rhythm Axis— left axis deviation 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 prolongation that would be consistent with 2nd Degree Type I or intermittent 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. Left axis deviation 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 duration(80 -110 ms). ST Segment— no marked elevation or depression QT Interval— normal Diagnosis: Bifascicular block (RBBB + LAFB) with first degree AV block Management: This EKG shows severe disease of the interventricular conduction system. A right bundle branch block with a left anterior fascicular block (or left posterior fascicular block) in the presence of a 1st degree AV nodal block is sometimes erroneously called a “trifascicular block”. Conduction between the atria and the ventricles is reliant on the remaining fascicle, in this case the left posterior fascicle. The long PR suggests that this remaining fascicle is also diseased, and thus the pa- tient is at risk of progressing to complete heart block. While a bifascicular block with concurrent 1st degree AV block is not an indication for a pacemaker on its own, patients with this rhythm who present with syncope should be admitted and evalu- ated for evidence of intermittent 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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