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Old 01-16-2014, 17:41   #16
Sdiver
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Here's the moment you've all been waiting for .... the answer.

In addition to the obvious STEMI, which is indeed an Inferior wall MI (as seen in leads II, III, and aVF, at least 3, possibly 4 mm elevation) this was/is a 2nd degree type I AVB, with 2:1 conduction and periods of 3:2, otherwise known as wenckebach.

Here's the same strip with marks pointing out the P-waves that "march out" with regularity. In lead I, you can see the P waves sitting on the down-ward slope of the T-wave with a dropped QRS. But the next p-wave associated with a QRS is right on time and on target.

Also, look at leads V1-V6. Notice anything "extra" ???
Is that a PVC or a PAC ???
Does it make a difference in your interpretation ???
Should you be concerned about it ???

Yes, the main focus is the STEMI and this person should be in a Cath-Lab ASAP, but as Adel pointed out, this is the kind of strip that one needs to slow down, take your time and hit the basics.

Heart blocks are a bitch to read sometimes. Everyone can pick out a 1st degree, and 3rds are relatively "easy", it's the two different types of 2nd degrees that throw people off.
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Old 01-16-2014, 17:49   #17
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What are the types of heart block?

First-degree heart block (also called first-degree AV block). The electrical impulses are slowed as they pass through the conduction system, but all of them successfully reach the ventricles. First-degree heart block rarely causes any symptoms or problems, and well-trained athletes may have this. Medications can contribute to the condition. No treatment is generally necessary for first degree heart block.

Type I second-degree heart block (also known as Mobitz Type I second-degree AV block or Wenckebach AV block). In this condition, the electrical impulses are delayed further and further with each heartbeat until a beat is skipped entirely. The condition generally is not as serious as type II second-degree heart block, but it sometimes causes dizziness and/or other symptoms. Normal people may sometimes have this when they are sleeping.
Type II second-degree heart block (Mobitz Type II second-degree AV block) is also a condition in which some of the electrical impulses are unable to reach the ventricles. This condition is less common than Type I, but is generally more serious. In some cases, a pacemaker is implanted to treat the abnormally slow heartbeat that may result from this condition.

Third-degree heart block (also known as complete heart block or complete AV block) is when none of the electrical impulses can reach the ventricles. When the ventricles, (lower chambers), do not receive electrical impulses from the atria (upper chambers), they may generate some impulses on their own called functional or ventricular escape beats. Ventricular escape beats, natural backup signals, usually are very slow, however, and cannot generate the signals needed to maintain full functioning of the heart muscle.

Bundle Branch Block is when electrical impulses are slowed or blocked as they travel through specialized conducting tissue in the ventricles.

http://arrhythmia.org/heartblock.html
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Old 01-17-2014, 00:06   #18
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As far as the STEMI goes I recall someone telling me that without S/Sx that elevated ST can be indicative of PRIOR MI. That once damage has been done it's permanent and therefore shows up on an EKG.

Again I've been out of the game for awhile and as I gain more FOG status with each day, my CRS keeps actin' up.
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Old 01-17-2014, 07:51   #19
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Thanks for the tutorial SDiver. Great exercise for the ol' noggin to think about things that I haven't thought about in years. Good therapy for the CRS syndrome too.
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Old 12-13-2015, 23:33   #20
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Quote:
Originally Posted by miclo18d View Post
As far as the STEMI goes I recall someone telling me that without S/Sx that elevated ST can be indicative of PRIOR MI. That once damage has been done it's permanent and therefore shows up on an EKG.

Again I've been out of the game for awhile and as I gain more FOG status with each day, my CRS keeps actin' up.
Your post got me thinking about persistence of ST segment changes post MI and I found this abstract about it.

http://www.ncbi.nlm.nih.gov/pubmed/1124714

Their conclusions were..."We concluded that (1) the natural history of S-T segment elevation after myocardial infarction is resolution within 2 weeks in 95 percent of inferior but in only 40 percent of anterior infarctions; (2) S-T segment elevation persisting more than 2 weeks after myocardial infarction does not resolve; (3) persistent S-T segment elevation is associated with clinically more severe myocardial infarction; and (4) in patients with coronary artery disease, persistent S-T segment elevation after myocardial infarction is a specific but insensitive index of advanced asynergy."
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Old 12-14-2015, 07:17   #21
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Great ECG and discussion!

It looks like the elevation is greater in III than II, which would definitely make me want to get a right sided ECG to evaluate for the inferior AMI (often a more proximal lesion of the right coronary artery). With the heart block and brady, thinking it is a right coronary artery lesion since in 80% of the population, this arterty feeds the AV Node.
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Old 05-09-2017, 02:24   #22
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Extreme Sinus Bradycardia; 3rd Degree (Complete) Heart block w/ Inferior/lateral STEMI.

HR seems to be less than 40.
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Old 05-15-2017, 15:56   #23
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Sinus bradycardia with 1st degree AV block and premature junctional contractions.
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Old 01-26-2019, 10:26   #24
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Another EKG

Alright here's a scenario for you based on a patient I saw not that long ago. Some inconsequential details have been changed.

19yo previously healthy young female PV2 is having a wild night out, gets drunk, and passes out on a dance floor. Seems pretty straightforward but something about the abruptness of the way she face planted rubs you the wrong way so you get an EKG and some labs. ETOH level is ~200. Currently drunk but not complaining of anything.

Additional questions? (Even if you are struggling with the EKG, what sorts of questions should you be asking?)

Thoughts?

MDs and the like hang back on this one before giving the game away.
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Old 01-27-2019, 19:20   #25
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Originally Posted by ender18d View Post
Alright here's a scenario for you based on a patient I saw not that long ago. Some inconsequential details have been changed.

19yo previously healthy young female PV2 is having a wild night out, gets drunk, and passes out on a dance floor. Seems pretty straightforward but something about the abruptness of the way she face planted rubs you the wrong way so you get an EKG and some labs. ETOH level is ~200. Currently drunk but not complaining of anything.

Additional questions? (Even if you are struggling with the EKG, what sorts of questions should you be asking?)

Thoughts?

MDs and the like hang back on this one before giving the game away.
Nice!! Great case and very important diagnosis to catch (if it's what I think it is)!


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Old 01-28-2019, 07:38   #26
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All the questions I want to ask are mimicked by drunkeness/hangover...
Headache? Dizzy? Nauseous?

Or am I going down the wrong street?
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Old 01-28-2019, 10:53   #27
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Quote:
Originally Posted by miclo18d View Post
All the questions I want to ask are mimicked by drunkeness/hangover...
Headache? Dizzy? Nauseous?

Or am I going down the wrong street?
Quick approach to transient loss of consciousness:

1. Is it syncope or is it seizure?
Convulsions (can be present for either but if prolonged more likely seizure)?
Post ictal period?
Incontinence?
Tongue biting?
Seizure history?

2. Is it syncope **AND?**
Syncope plus other symptoms can have a huge differential. In the right context, syncope AND abdominal pain could be AAA. Syncope AND dyspnea could be PE. Syncope AND headache could be SAH. Syncope and pregnant could be ectopic. Figure out if there are other concerning symptoms.

3. Red flags for syncope.
If you set aside syncope with significant and/or ongoing associated symptoms for a moment, almost all scary causes of syncope are cardiac. So some red flags that should scare you point to cardiac causes of syncope:
-Pain. Along the lines of #2, benign syncope should not hurt.
-“Lights out” with no prodrome. Suspect this if injured in fall esp.
-Syncope during exertion. Passing out after exertion is not uncommon, but during exrtion should scare you.
-history of cardiac disease
-family history of sudden cardiac or unexplained death
-Patient is elderly
-new/unexplained murmur

**So back to our patient:
1. No historical features to suggest seizure.
2. No associated symptoms not explained by ETOH. Neg HCG.
3. A few big red flags: she went out quickly with no prodrome and possibly (story fuzzy) while dancing. Her father died in his 30’s in his sleep and no one was ever sure why.
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Old 01-29-2019, 13:46   #28
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So most of the MDs have PMd me and identified the rhythm, and I think no one else is going to wade in, so the answer:

This patient had Brugada Syndrome, a channelopathy that can predispose patients to arrhythmia and sudden cardiac death. Its an autosomal dominant genetic disorder, and this is likely what claimed her father's life. The EKG findings of Brugada are not always present (you can have a normal prior EKG) and Brugada "attacks" can be precipitated by alcohol use. This patient's EKG normalized when she sobered up.

She was admitted to Cardiology for an AICD placement.

Brugada has different forms, but should be considered in a syncopal patient with EKG findings of ST elevation in V1-3, especially if combined with T wave inversion as seen in this EKG.

If y'all want to keep going I have some other good real patient syncope scenarios for you.
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Old 01-31-2019, 09:04   #29
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As the namesake for my nomme de plume would say, "Finest Kind!"

Seriously, Thank you all for contributing to this discussion!
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Old 02-02-2019, 05:52   #30
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Way above my pay grade!

Put a GSW in front of me and I’ll make you proud!
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