Ekg help!!!

[BaylorEMT]

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Hi, I'm still a student and learning EKGs. I'm practicing my EKG rhythms and thought I'd ask the EKG masters for their opinions. From my studies, I believe the pt has a LBBB and LVH. However, it does not give me the correct answer so I am stuck wondering if I was right or it is wrong 🙁 Can y'all at least validate if I am right or wrong in believing it is LBBB and LVH? Thank you for your time 🙂

 

[BlackNDecker]

I am going to try to help you answer your own question...rather than giving the answer.

First look to see if the QRS is > 120 msec. Next, look at lead V1 for RBBB and lead I and V6 for LBBB. Now, look to see which direction the terminal deflection in these leads is traveling (positive deflection means the depolarization is coming towards you). If the terminal deflection is upward in I and V6, that means the delayed portion of the depolarization wave (aka the block) is traveling towards those leads. Likewise, a negative terminal deflection in these leads means that the delayed component of the depolarization wave is traveling in the opposite direction.

Lastly, there are specific criteria for LVH. You can google these...best bet is to use at least 2 criteria to quickly screen for LVH, if not present, move on.

Feel free to post back with your thoughts in regards to the above. Hope that helps👍

 

[adagio]

A good mnemonic for LBBB: Low Mood 6 (LBBB is M shape on V6)

and for RBBB: Very Right So Right One (V1 RSRprime)

Sokolov-Lyon criteria for LVH as far as I recall. I dont know if they are outdated

 

[BlackNDecker]

A good mnemonic for LBBB: Low Mood 6 (LBBB is M shape on V6)

and for RBBB: Very Right So Right One (V1 RSRprime)

Sokolov-Lyon criteria for LVH as far as I recall. I dont know if they are outdated

Once you understand cardiac conduction in terms of vectors (i.e. Direction of current) it will make the EKG much much easier to interpret. Pattern recognition (i.e. RSR') will fail you on occasion. But if all you really want to do is rule out acute STEMI then you'll probably be ok with pattern recognition😀

 

[adagio]

Hahaha ... I agree to death!!

Problem is: USMLE questions required us making decisions in a terribly sort period of time. Hence the mnemonics even though once one understand which wall gets depolarized first and how it spreads, it should be straightforward

 

[BlackNDecker]

Hahaha ... I agree to death!!

Problem is: USMLE questions required us making decisions in a terribly sort period of time. Hence the mnemonics even though once one understand which wall gets depolarized first and how it spreads, it should be straightforward

I read a really interesting (and thin book) back during MS4 year called vectorial analysis of EKG or something similar. I picked it up on Amazon. It was fascinating to see how the 12 lead EKG can actually pinpoint the location of a lesion or ischemia in the myocardium (not to be confused with a general vascular territory)...by analyzing the vector of the T waves and/or ST abnormalities. EP guys use this type of approach, albeit with much more precision and many more leads and orders of magnitude more complexity.

 

[BlackNDecker]

OP never came back, but I was hoping he would realize he made a mistake interpreting the EKG above and would post his correction after reading through my feedback.

 

[adagio]

Is it Digoxin effect BND?

 

[adagio]

I think there is no hypertrophy, i always look for the isoelectric point on the V leads and see whether its shifted or not to determine H.

Inferior leads II, III, aVF looks normal so I dont think there is RVH

 

[adagio]

There is T inversion in V1, is it a form of RVH? especially that isoelectric point is shifted towards V2?

Its either this or RBBB I think. The prolonged QRS duration in V1 makes me thing RBBB more than RVH

 

[adagio]

So in summary, no signs of RV strain (Hypertrophy or PE) according to inferior leads, and a prolonged QRS on V1 with an inverted T ... RBBB?


(There is a weird scooping in I, but I guess this could be artifact)

 

[adagio]

I read a really interesting (and thin book) back during MS4 year called vectorial analysis of EKG or something similar. I picked it up on Amazon. It was fascinating to see how the 12 lead EKG can actually pinpoint the location of a lesion or ischemia in the myocardium (not to be confused with a general vascular territory)...by analyzing the vector of the T waves and/or ST abnormalities. EP guys use this type of approach, albeit with much more precision and many more leads and orders of magnitude more complexity.

Could you stop please providing me with approximations of stuff that cant be found 😀 I couldnt find anything yet on googl!!!!!

 

[adagio]

Here is a lecture that has this title, was able to find it on the net

 

[adagio]

http://www.youtube.com/watch?v=yJCFO5qJW84

 

[adagio]

A paper that has the same title.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1018145/pdf/brheartj00344-0014.pdf

 

[BlackNDecker]

LMAO...adagio, your crazy.

By convention, a positive deflection in leads...
1) V1 - the current is moving rightward
2) I, V6 - the current is moving leftward

Yes, criteria for RBBB is present. (there may be other subtle findings but i honestly didnt look). Once you know QRS duration is >120 msec, there has to be a bundle branch block. If you just look at the vectors, the terminal deflection is upward (positive) in V1...that means the final current (the current that is delayed) is coming towards V1 (i.e. the right side of the heart). Look closely...in lead V1 there is an initial rapid downward (left) deflection followed by a long widened upward (right) deflection. The latter prolonged waveform shows you where the block is.

On the other hand, the terminal deflection is negative in I and V6...this means the delayed portion of the current is moving away from the left heart towards the right heart.

Both pieces of info tell you the same thing...that there is a RBBB. If you will think about this and let it sink in you will "get it."

 

[adagio]

Great!! RBBB ... But still I must brush up on my EKG reading abilities (There are a few books I intend to read prior to july, and re-reading Dubin and/or Hampton is one of them.

So this (scooping) is indeed an artifact right?

 

[adagio]

to BND :Suave con los manos, fuerte contra las grasas

http://youtu.be/YqecOmezgSw

 

[tibor75]

An ECG costs $175?

No wonder healthcare will bankrupt our country...