October 2017 Tracings

Transcription

1 Tracings Tracing 1 Tracing 4 Tracing 1 Answer Tracing 4 Answer Tracing 2 Tracing 5 Tracing 2 Answer Tracing 5 Answer Tracing 3 Tracing 6 Tracing 3 Answer Tracing 6 Answer Questions? Contact Dr. Nelson wpan747@gmail.com Visit the web site!

2 March 10 March Year old man. Tracing 1 What are the possibilities regarding these 2 tracings?? What is Kulbertus block?

3 March 10 March Year old man. Tracing 1: Answer What are the possibilities regarding these 2 tracings?? What is Kulbertus block? The frontal plane axis is (-) 70 degrees, consistent with Left Anterior fascicular block. The only unusual feature is the prominent R wave in leads V Possibilities: 1. Too much anterior RV (RVH) -- but the left axis would be against this Too little posterior LV (posterior MI) -- possible 3. Kulbertus Block -- Dr. Henri Kulbertus emphasized that, in addition to a left anterior and posterior fascicle, many people own a mid-septal fascicle of the LBB -- and thus have a quadrifascicular conduction network. He postulated that if there was mid-septal fascicular block the early QRS forces would become oriented anteriorly, inscribing a prominent initial R wave in V1-2. I think that this 3rd possibility is the most romantic -- if not the correct one... The lower tracing shows that RBBB has been added. The initial forces are unchanged and now the composite of conduction abnormalities is RBBB, LAFB, and Kulbertus block -- 3 of the 4 pathways have bit the dust...agree?

4 66 Year old woman. Tracing 2 Do you agree with the reviewer?

5 66 Year old woman. Tracing 2: Answer Do you agree with the reviewer? The reviewer s observations are pretty close to the mark. It is unclear whether the right axis deviation is due to the lateral infarction or LPFB. An important issue is the rhythm. The baseline artifact adds confusion, but is it sinus tachycardia of 130/min. or could the little deflections in V1 (arrows) represent P waves?? Carotid sinus message provides the truth - - the atrial mechanism is atrial flutter with 2:1 ventricular conduction. Stay alert! Were you correct??

6 78 Year old man. Tracing 3 Peculiar pacer performance! What is happening?

7 78 Year old man. Tracing 3: Answer Peculiar pacer performance! What is happening? This is an example of endless-loop tachycardia. The patient had a dual chamber pacemaker implanted several weeks before presenting to the E.D. with this rhythm. Dual chamber (A-V sequential) pacemakers are designed to simulate normal sinus rhythm however, if the A-V bridge is intact, and the atrial refractory period is short, the ventricular stimulus may return to the atrium. The atrial discharge is sensed and the ventricular limb is triggered to fire again. The sequence then becomes repetitive: ventricle-to-atrium-toventricle-to-atrium-etc. -- and an endless loop tachycardia results. The magnet influence prevents atrial and ventricular sensing and interrupts the pacemaker mediated tachycardia.

8 49 year old man Which diagnosis would Tracing 4 you choose?? December 18

9 49 year old man Tracing 4: Answer Which diagnosis would you choose?? At EKG conference, it would be easy to sell the upper tracing as an example of pericarditis: diffuse S T segment elevation without reciprocal depression and tantalizing P R segment depression. However- for your frustration and disappointment, the lower tracing shows an acute antero-lateral infarction is evolving. Stay humble!! December 18 December 21 - Did you make the correct choice?

10 63 Year old man. Tracing 5 Do you agree with the reviewer??

11 63 Year old man. F Tracing 5: Answer Do you agree with the reviewer?? VPC F The (*) statement was provided by the reviewer -- let s disagree with him (or her)!! The barrages of wide-qrs complexes at 140/min. are clearly ventricular!! The 2 sinus beats identify the normal morphology. The bizarre RBBB pattern of the wide QRS in lead V1, the 15mm S-wave in V6 (Marriott s sign), the dissociated P waves (arrows), the fusion beats (F), and the broad R-to-S in V2 (Brugada sign) add up to a convincing diagnosis. A single VPC of different origin sullies things...

12 54 Year old man. Tracing 6 Multiple FLB s -Due to??

13 50 Year old woman. C.O.P.D. Tracing 6: Answer Your observations please: There is some variability of the slow sinus node discharge. When the rate is slow enough, an escape ventricular focus surfaces -- QRS #4 (Arrow). It identifies the pure QRS morphology when there is abnormal ventricular excitation. Complexes #2 & 6 are the only normal complexes (making analysis of the 12 lead tracing difficult -- but inferior and anterior MIs are probable)... The configuration of complexes #1-3-5-& 7 indicate simultaneous activation of the ventricles by the atrial and ventricular stimuli -- fusion beats... questions??