Can someone tell me what's up with this ECG

[cbrons]

No P-waves, irregular non-patterned rhythm (atrial fibrillation?) The practice ECGs they give us don't even have a rhythm strip from lead 2 so its frustrating. I also know there is a left axis deviation based on the reading in aVF & I.

** this is not "homework help" btw **

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[fiznat]

(*in response to now deleted post...)

Isnt that RBBB?

 

[Dwindlin]

accelerated junctional rhythm with a RBBB me thinks.

 

[Venko]

Atrial fibrillation / flutter with bifascicular block and nonspecific ST segment abnormalities in the lateral leads.

 

[doctorFred]

would be nice to slow it down a bit.

looks like flutter with a RBB? particularly fluttery in V1 and V2.

 

[joeDO2]

i agree with the others that it is clearly RBBB with pathological left axis deviation suggestive of a bifasicular block. also of note are t-wave inversions in the precordial leads with non-specific ST depressions. there is a lack of R wave progression. as for the rhythm, it appears there are some p-waves with a variable P-R. it is difficult to say for certain at this rate but I would consider a multifocal atrial tachycardia. it would of course be helpful to understand the patients clinical presentation. without a baseline ecg / H&P ischemia must be ruled out as well as PE (tachycardia with RBBB).

 

[cbrons]

Apparently the answer is A.fib with right bundle branch block and left anterior fascicular block (termed bifascicular block). But I get the A.fib and the RBBB part. Where are they getting LAFB? And what would be the treatment? (asking because I am curious, I don't need to know this right now, just the interpretation).

 

[Rendar5]

Apparently the answer is A.fib with right bundle branch block and left anterior fascicular block (termed bifascicular block). But I get the A.fib and the RBBB part. Where are they getting LAFB? And what would be the treatment? (asking because I am curious, I don't need to know this right now, just the interpretation).

The axis deviation is what defines the bifascicular block. RBBB + LAD = RBBB + LAHB. You don't treat it, it's an electrical phenomenon that requires you to look into possible causes. This could simply be his baseline and whatever treatment you do for him is his chronic treatment. I will say that new onset sinus tach, Afib, and RBBB's are 3 things which may show up in PE or some other cause of sudden right heart strain.

 

[TrumpetDoc]

For sure the bifasicular block.
One would consider also flutter with variable block going on as well.

 

[KYTNOH]

i agree with the others that it is clearly RBBB with pathological left axis deviation suggestive of a bifasicular block. also of note are t-wave inversions in the precordial leads with non-specific ST depressions. there is a lack of R wave progression. as for the rhythm, it appears there are some p-waves with a variable P-R. it is difficult to say for certain at this rate but I would consider a multifocal atrial tachycardia. it would of course be helpful to understand the patients clinical presentation. without a baseline ecg / H&P ischemia must be ruled out as well as PE (tachycardia with RBBB).

Those T-waves and ST-segments are normal in bundle branch blocks. It's called the rule of appropriate discordance. Repolarization is altered because of the abnormal timing of depolarization of the ventricles. The T-wave and ST segments should have a vector that is opposite the vector of the terminal R or S wave. Although it isn't very specific, what you don't want is concordant ST segments and T waves in the setting of a LBBB or RBBB. There's something called the sgarbossa criteria that helps in identifying evidence of ischemia

It looks like Afib with RVR to me. Flutter is much less likely. Flutter typically gives you QRS intervals that are super consistent in a 2:1 or 3:1 block. If there is a variable block you'll have some QRS intervals that would equate to a 2:1 block and others that would equate to a 3:1 block.

 

[diphenyl]

Apparently the answer is A.fib with right bundle branch block and left anterior fascicular block (termed bifascicular block). But I get the A.fib and the RBBB part. Where are they getting LAFB? And what would be the treatment? (asking because I am curious, I don't need to know this right now, just the interpretation).

Yep afib w/ RVR and a RBB. Treatment? This decision is multi factorial. Is the patient having chest pain? Is this significantly different from the previous EKG? For a new RBBB they need to have ACS ruled out. For new onset afib chemical cardioversion is indicated. Any person with this EKG though, if they are symptomatic with chest pain, probably need to be admitted or placed on observation pending serial cardiac enzymes and a stress test.

 

[TrumpetDoc]

Those T-waves and ST-segments are normal in bundle branch blocks. It's called the rule of appropriate discordance. Repolarization is altered because of the abnormal timing of depolarization of the ventricles. The T-wave and ST segments should have a vector that is opposite the vector of the terminal R or S wave. Although it isn't very specific, what you don't want is concordant ST segments and T waves in the setting of a LBBB or RBBB. There's something called the sgarbossa criteria that helps in identifying evidence of ischemia

It looks like Afib with RVR to me. Flutter is much less likely. Flutter typically gives you QRS intervals that are super consistent in a 2:1 or 3:1 block. If there is a variable block you'll have some QRS intervals that would equate to a 2:1 block and others that would equate to a 3:1 block.

Indeed, very true...just wanted to remind that aFltr in ddx of suspected afib. Not to say I havnt been fooled on a sure AFrvr and found to be flutter.

 

[mauricekenter]

I was under the impression "appropriate discordance" was only applicable to a LBBB and doesn't apply to a RBBB. The only ST changes in a RBBB should be ST-depression in V1-3. Please educate me if I am wrong here.

 

[tbouthillet]

I was under the impression "appropriate discordance" was only applicable to a LBBB and doesn't apply to a RBBB. The only ST changes in a RBBB should be ST-depression in V1-3. Please educate me if I am wrong here.

With LBBB most authors use the main deflection (majority of the QRS complex) to determine appropriate discordance. As luck would have it, in most cases with LBBB the main deflection is the terminal deflection.

With RBBB we use the terminal deflection. Sometimes this is the main deflection (as in lead V1) but sometimes the main deflection is positive but the terminal deflection is negative (like an Rs complex in lead I and V6). In those cases the T-wave should be positive.

For example, in this case leads I, V5 and V6 are abnormal because the T-waves are concordant (in the same direction as the terminal deflection) and in theory that's abnormal for RBBB. Having said that, this isn't just a RBBB, it's a bifascicular block, and some of the complexes (like lead aVL) look more like LBBB.

To further complicate matters I have noticed that it's not uncommon for a lead near the transition of the terminal deflection from positive to negative to show a concordant T-wave in the setting of bifascicular block.

For example:
http://3.bp.blogspot.com/_2MjIeQJj8UM/SdYXy2d7P-I/AAAAAAAAAqQ/fgdGbiPQyNo/s1600-h/TOMB040209Bb.JPG

Here we see a concordant T-wave in lead V3 but it's a transition lead (the terminal deflection becomes negative in V4). So as the terminal deflection transitions from positive to negative the T-waves should transition from negative to positive and this isn't always "perfect".