EKG ConferenceEKG Conference
August 30, 2007August 30, 2007
David Stultz, MDDavid Stultz, MD
Southwest Cardiology, Inc.Southwest Cardiology, Inc.
(c) 2000-2008 David Stultz, MD
Review from Last SessionReview from Last Session
Heart RateHeart Rate
1 big box = 200ms1 big box = 200ms
1 small box = 40ms1 small box = 40ms
6060
55
5050
66
42427575100100150150300300Heart RateHeart Rate(300/big boxes)(300/big boxes)
7744332211Big BoxesBig BoxesBetween QRSBetween QRScomplexescomplexes
(c) 2000-2008 David Stultz, MD
11stst Degree AV BlockDegree AV Block
>200 ms from onset of P wave to onset of QRS>200 ms from onset of P wave to onset of QRS
(c) 2000-2008 David Stultz, MD
22ndnd Degree AV BlockDegree AV BlockType 1Type 1 -- WenkebachWenkebach
PP--R interval prolongs until QRS is droppedR interval prolongs until QRS is dropped
(c) 2000-2008 David Stultz, MD
22ndnd Degree Heart BlockDegree Heart BlockType 2Type 2
PR interval remains constant, QRS dropsPR interval remains constant, QRS dropsunexpectedlyunexpectedly
(c) 2000-2008 David Stultz, MD
33rdrd degree Heart Blockdegree Heart Block
P rate faster than QRS rateP rate faster than QRS rate
No correlation between PNo correlation between P’’s and QRSs and QRS
(c) 2000-2008 David Stultz, MD
Bundle Branch BlocksBundle Branch Blocks
Right Bundle Branch BlockRight Bundle Branch Block
QRS duration >120ms (3 small boxes)QRS duration >120ms (3 small boxes)
rsRrsR’’ in V1in V1
‘‘Rabbit EarsRabbit Ears’’
(c) 2000-2008 David Stultz, MD
Bundle Branch BlocksBundle Branch Blocks
Left BundleLeft BundleBranch BlockBranch Block
QRS durationQRS duration>120ms (3 small>120ms (3 smallboxes)boxes)
R in V6R in V6
(c) 2000-2008 David Stultz, MD
Left Anterior Fascicular BlockLeft Anterior Fascicular Block
Frontal AxisFrontal Axis --45 to45 to --90 degrees90 degrees
QRS <120msQRS <120ms
rSrS pattern in II, II,pattern in II, II, aVFaVF (inferior leads)(inferior leads)
(c) 2000-2008 David Stultz, MD
Left Posterior Fascicular BlockLeft Posterior Fascicular Block Frontal Axis +/Frontal Axis +/--120 degrees (typically right axis deviation)120 degrees (typically right axis deviation)
QRS <120msQRS <120ms
RS pattern I,RS pattern I, qRqR pattern in II, II,pattern in II, II, aVFaVF (inferior leads)(inferior leads)
(c) 2000-2008 David Stultz, MD
QRS Duration <120ms
LAHB (LAFB)Severe LAD without explanation•Deep S waves in II, III, aVF•Frontal Axis <-45 to -60 degrees•Positive in I, Negative in aVF•Not explained by LBBB, LVH, inferiorinfarct
LPHB (LPFB)Opposite of LAFB, Rare•Usually Right Axis deviation•Negative in I, Positive in aVF•Positive in II, III, aVF•Not explained by RVH, anterolateralinfarct
Fascicular BlocksFascicular Blocks
Schedit, S. Basic Electrocardiography. CIBA-GEIGY Pharmaceuticals, USA, p 49.
(c) 2000-2008 David Stultz, MD
An interesting caseAn interesting case
58 year old female admitted with syncope58 year old female admitted with syncope
Seen 2 weeks ago at previous hospital forSeen 2 weeks ago at previous hospital forsyncope, had negative workupsyncope, had negative workup
Describes someDescribes some clonicclonic motions during syncope,motions during syncope,having workup for seizureshaving workup for seizures
(c) 2000-2008 David Stultz, MD
Overnight telemetryOvernight telemetry
Probably sinus rhythm with 2nd degree type 2 heart block
3rd degree heart block
(c) 2000-2008 David Stultz, MD
Rapidly progressive heart blockRapidly progressive heart block
Dual chamber pacemaker implantedDual chamber pacemaker implanted
During a portion of testing of pacemaker theDuring a portion of testing of pacemaker thefollowing day, only the atrial lead was pacedfollowing day, only the atrial lead was paced
(c) 2000-2008 David Stultz, MD