Scenario
A 72 year old woman is brought to your Emergency Department after a syncopal episode.
Question
a. Describe and interpret her ECG (50%) b. Outline your disposition considerations (50%)
Answer
FACEM VAQ Exam 2009.1 – Question 1
- The overall pass rate for this question was 26/81 (32.1%)
- ECG showing first degree heart block, left axis deviation and RBBB.
- The examiner pair felt that this was a core EM scenario that was done very poorly by the majority of candidates.
- Pass criteria were to identify the ECG features above plus appreciate the conduction implications of this in the presence of syncope with need for monitoring and potentially pacing.
ACEM Fellowship Visual Aid Questions
About Mike Cadogan
Hi Stand,
I agree there is a bit of a blip around the T wave after the 7th complex, but I don’t think it is CHB. Mapping out all the definite P waves shows that they are all followed by QRS complexes with a prolonged but equal PR interval.
A few blips due to electrical noise or movement are to be expected.
Chris
this is COMPLETE HEART BLOCK with A-V dissociation and a ventricular escape rythm
she should be immediately referred for temporary pacemaker implantation
Tiene un bloqueo A-V de primer grado mas un bloqueo completo de rama derecha mas un bloqueo de rama rama izquierda antero superior
If the PW’s are doing thier own thing and the QRS’s are doing thier own thing….this would be the definition of a CHB.
I do not see more PW’s then QRS’s indicating AV dissociation. If there are more PW’s then QRS’s, it is a 2:1 block. The PRI is consitant throughout @ 360ms. Can a PW take 360 ms to conduct through to the ventricles?……..I don’t know (pretty long time). If it is a 2:1 conduction in which the second PW does, in fact, conduct through to the ventricles, then it would be a 2nd degree HB type II (classic) HB, not a CHB. I agree with all responders that this person is a very strong candidate for a pacemaker insertion as long as the cause is not reversable. This patient does have a patholocal left axis deviation with a ventricular axis of approximately -40 degrees indicating a LAFB and a RBBB pattern in V1 (Bifascicular Block), and a 1st degree AVB which would make this actually a trifascicular block. All of which would be strong indicators that this patient is in danger of going into a CHB.
With the pacemaker pads inplace, I would attempt a trial dose of Atropine Sulfate @ 0.5 mg to see if this speeds things up until labs and other tests can be completed. As well as a Cardiology consult for possible pacemaker insertion.
Nick Adams, NREMT-P, FP-C
although the PRI is very long ( perhaps the longest i have seen ), there is a constant relation between the P waves and the QRS complexes. If this were to be a complete heart block with an infra nodal ( junctional or ventricular escape rythm, I would expect a slower rate than this . Also there is no ” grouped beating ” so a 2nd degree HB is not present. It is indeed a tri fascicular block ( which is in effect not unlike a complete HB !). Her disposition would be admission to a monitored bed ( with temporary pacing pads on ) with a plan for a PPM insertion. I wouldn’t necessarily give her any atropine unless she goes into bradycardia with haemodynamic compromise.