New Onset RBBB?!

[Rendar5]

Perhaps this belongs in cardiology first, but wanted to run it by here. Had a patient today, presents with a good hypoglycemic fall story. Type I DM in his 50s (hx 2 MIs), woke up sweaty and weak, goes to shower, goes AMS per gf, falls, breaks 4 ribs, is given sugar at home, fs 35, regains mental status, gets more glucose in ambulance ride over and then I see him. Has a bit of fluid behind one of his lungs, so we have him drink contrast for a CT. I come back and check in on him. Cold, sweating up a storm, weak, lethargic. Gets D50, we check fs afterwards and it's in 300s. Assume it's another hypoglycemic episode since he took his lantus in the AM and didn't eat. But he's slow coming around, and is still lethargic an hour later.

So here's the mystery: I check his EKG, 6 hours earlier - normal, now - he has a RBBB, with maybe a T-wave flattening in V2, and maybe left atrial enlargement (whichever one produces wide p waves). He's ticking away at 60bpm, no CP, no worsening SoB. Anyone have any idea whatsup?

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[Hard24Get]

I'm no expert, but with a new RBBB, I'd think cardiac contusion in this case since there was trauma, or MI because of his risk factors (esp since diabetics can have silent MIs). I would definitely ROMI. Also, with the lethargy and history of trauma, did he get a head CT?

 

[WilcoWorld]

Right heart strain & what sounds like multiple syncopal events. In addition to ACS, you've got to consider PE. Quite possible that the hypoglycemia is a red herring, or just a manifestation of his other pathology.

 

[leviathan]

Perhaps this belongs in cardiology first, but wanted to run it by here. Had a patient today, presents with a good hypoglycemic fall story. Type I DM in his 50s (hx 2 MIs), woke up sweaty and weak, goes to shower, goes AMS per gf, falls, breaks 4 ribs, is given sugar at home, fs 35, regains mental status, gets more glucose in ambulance ride over and then I see him. Has a bit of fluid behind one of his lungs, so we have him drink contrast for a CT. I come back and check in on him. Cold, sweating up a storm, weak, lethargic. Gets D50, we check fs afterwards and it's in 300s. Assume it's another hypoglycemic episode since he took his lantus in the AM and didn't eat. But he's slow coming around, and is still lethargic an hour later.

So here's the mystery: I check his EKG, 6 hours earlier - normal, now - he has a RBBB, with maybe a T-wave flattening in V2, and maybe left atrial enlargement (whichever one produces wide p waves). He's ticking away at 60bpm, no CP, no worsening SoB. Anyone have any idea whatsup?

I'm not a medical student, but with a +++ cardiac history and DM combined with the "unwell" appearance, I would want to rule out MI and check his trops. The previous infarcts combined with the DM put him at risk for atypical or silent presentation of an MI.

 

[Rendar5]

Well, to answer some questions and for some follow-up:
He was indeed pan-scanned because of the witnessed head trauma in addition to the 4 rib fractures. Head and neck were negative, chest did show small amounts of fluid which were not drained by surg. Abdomen showed fluffy looking pyramids in the kidneys (pyramids looked like cotton balls), which radiology wasn't quite sure what to make of. Previous CTs showed similar but less advanced changes: suggested looking for pyelo, not consistent with diabetic changes (not sure if this was followed up). Initial cardiac markers were negative. We admitted to telemetry floor.

In the system, I checked and he's been tehre for a few days, They're following his CKs which ranged up to 800 at one point. I'm not quite sure of the reason. A u/a showed large blood, with 60 RBS/hpf (so doesn't sound like rhabdo to me). troponins were all normal. He was also dx'd with pneumonia on day 2/3, based on repeat X-ray and labs, but never developed a fever.

Unfortunately, I don't know the full story since I dont' know his docs.

 

[southerndoc]

Some people have transient RBBB's. One of my colleagues has a transient RBBB.

 

[Jeff698]

Some people have transient RBBB's. One of my colleagues has a transient RBBB.

Does anyone remember the name of the syndrome that is basically a rate-induced conduction disturbance? I'm having one of these "on-the-tip-of-my-tongue" moments.

Take care,
Jeff

 

[southerndoc]

Does anyone remember the name of the syndrome that is basically a rate-induced conduction disturbance? I'm having one of these "on-the-tip-of-my-tongue" moments.

Take care,
Jeff

There are a bunch of transient conduction abnormalities. Are you thinking of Brugada (transient RBBB with ST elevation in V1-V2)?

 

[WilcoWorld]

I've seen "rate related bundle branch block" multiple times, but I've never been aware of a more specific name for them.

 

[Jeff698]

There is an eponym for at least one of them. I think it may even begin with a B but I don't think it is Brugada although the Brugada brothers seem to have been very productive in an academic sense.

As far as I know, rate related RBBB isn't associated with the Brugada syndrome that we look for (the one caused by the sodium channel defect).

Grrrr, now I'm going to have to do something vaguely medical and look this up. I was really enjoying my two weeks of brain free activity.

Take care,
Jeff

 

[southerndoc]

Brugada is transient, but I'm not sure if it's rate related.

I'm not sure what eponym is associated with a pure rate-related RBBB.

RBBB's in asymptomatic males are present in about 10% of the population and have no bearing on mortality. RBBB's in symptomatic males are associated with higher mortality.

 

[Substance]

Could it be a PE?

New onset RBBB could represent right heart strain. Seeing as how he has a lot of vessel damage due to longstanding diabetes, he could've dislodged a DVT when he fell due to the presumed hypoglycemic syncope. Or it could be a PE all along with the hypoglycemia a red-herring.

His long-standing diabetes could likely denervate his heart, and thus he would not manifest chestpain or tachycardia in response to a PE.

Was a Ddimer and doppler US done?