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EKG Rounds

EKG Rounds. Rebecca Burton-MacLeod R4, Emerg Med July 20 th , 2006. EKG Case . Conduction anatomy . AV node Bundle of His Branching bundle Bundle branches Purkinje fibers Myocardial cells. Bundle branch blocks. RBBB—transmission is delayed or fails to conduct along right bundle branch

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EKG Rounds

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  1. EKG Rounds Rebecca Burton-MacLeod R4, Emerg Med July 20th, 2006

  2. EKG Case

  3. Conduction anatomy • AV node • Bundle of His • Branching bundle • Bundle branches • Purkinje fibers • Myocardial cells

  4. Bundle branch blocks • RBBB—transmission is delayed or fails to conduct along right bundle branch • LBBB—transmission is delayed or fails to conduct along left bundle branch • LAFB—most common type of intraventricular conduction defect • LPFB—very rare!

  5. Terminology • Bifascicular block—conduction defect in RBB and either LAF or LPF • Does not include RBBB and LBBB combination, as this is termed 3rd degree AV block • Trifascicular block—as above, with 1st degree AV block (prolonged PR)

  6. Conduction • Consequence of BBB is that ventricle must await depolarization by opposite ventricle • Activation proceeds on cell-to-cell basis • Results in much slower activation along normal pathways

  7. RBBB • Causes: • In children—surgical repair of VSD’s is most common cause; cardiomyopathy, myocarditis, CHF, hereditary causes (Brugada syndrome), muscular dystrophy • In adults—normal variant, RVH or strain (ex: PE), CAD

  8. RBBB PE • What will you hear on physical examination? • Persistently split S2

  9. RBBB EKG findings

  10. RBBB

  11. EKG criteria • QRS >0.1sec • rSR’ or rR’ pattern in V1-3 • Wide S in leads I, V6 • May have normal axis, or right or left deviation • Usually inverted T in V1-2, in other leads T is directed opposite to terminal portion of QRS

  12. CAD Cardiomyopathy Myocarditis LVH Anatomic malformations Neuromuscular disease Hemochromatosis Aortic valve endocarditis RHD Perinatal exposure to HIV-I LBBB causes

  13. LBBB PE • What heart sound changes will you hear on auscultation? • Absent or diminished S1, reverse split S2

  14. LBBB EKG findings

  15. LBBB EKG

  16. EKG findings • QRS >0.12sec • No Q in I, aVL, V6 • Prominent QS pattern in V1 (+/- small R wave) • Tall, wide, notched R in I, aVL, V6

  17. LAFB • EKG findings: • Normal QRS width • QRS axis is from –30 to –90degrees • Q present in I, aVL • Major QRS direction in aVF is negative • Slurred S wave in left precordial leads • Late R wave in aVR (>0.045sec) • Terminal R in aVL is slurred

  18. EKG

  19. LPFB Ddx • Must first exclude other causes of right axis!!! • Cor pulmonale • Pulmonary heart disease • Pulmonary hypertension, etc.

  20. LPFB • EKG findings: • Duration of QRS is usually normal • Q wave present in II, III, aVF • QRS axis is +120 to +180degrees • S wave present at end of QRS in I and aVF

  21. EKG

  22. Tough scenarios with BBB • RVH • LVH • MI

  23. MI ?

  24. MI ?

  25. MI ?

  26. Sgarbossa criteria • STE >1mm concordant with QRS (5pts) • STD >1mm in V1-3 (3pts) • STE >5mm discordant with QRS (2pts) • >3pts =AMI Sgarbossa et al. NEJM. 1996

  27. EKG smorgasbord

  28. EKG smorgasbord cont’d

  29. EKG smorgasbord cont’d

  30. EKG smorgasbord cont’d

  31. EKG smorgasbord cont’d

  32. EKG smorgasbord cont’d

  33. Questions?

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