EKG ConferenceEKG Conference

August 30, 2007August 30, 2007

David Stultz, MDDavid Stultz, MD

Southwest Cardiology, Inc.Southwest Cardiology, Inc.

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

Normal EKGNormal EKG

(c) 2000-2008 David Stultz, MD

Review from Last SessionReview from Last Session

Heart RateHeart Rate

1 big box = 200ms1 big box = 200ms

1 small box = 40ms1 small box = 40ms

6060

55

5050

66

42427575100100150150300300Heart RateHeart Rate(300/big boxes)(300/big boxes)

7744332211Big BoxesBig BoxesBetween QRSBetween QRScomplexescomplexes

(c) 2000-2008 David Stultz, MD

11stst Degree AV BlockDegree AV Block

>200 ms from onset of P wave to onset of QRS>200 ms from onset of P wave to onset of QRS

(c) 2000-2008 David Stultz, MD

22ndnd Degree AV BlockDegree AV BlockType 1Type 1 -- WenkebachWenkebach

PP--R interval prolongs until QRS is droppedR interval prolongs until QRS is dropped

(c) 2000-2008 David Stultz, MD

22ndnd Degree Heart BlockDegree Heart BlockType 2Type 2

PR interval remains constant, QRS dropsPR interval remains constant, QRS dropsunexpectedlyunexpectedly

(c) 2000-2008 David Stultz, MD

33rdrd degree Heart Blockdegree Heart Block

P rate faster than QRS rateP rate faster than QRS rate

No correlation between PNo correlation between P’’s and QRSs and QRS

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

Bundle Branch BlocksBundle Branch Blocks

Right Bundle Branch BlockRight Bundle Branch Block

QRS duration >120ms (3 small boxes)QRS duration >120ms (3 small boxes)

rsRrsR’’ in V1in V1

‘‘Rabbit EarsRabbit Ears’’

(c) 2000-2008 David Stultz, MD

Bundle Branch BlocksBundle Branch Blocks

Left BundleLeft BundleBranch BlockBranch Block

QRS durationQRS duration>120ms (3 small>120ms (3 smallboxes)boxes)

R in V6R in V6

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

Bundle Branch Block CriteriaBundle Branch Block Criteria

(c) 2000-2008 David Stultz, MD

AxisAxis

(c) 2000-2008 David Stultz, MD

Left Anterior Fascicular BlockLeft Anterior Fascicular Block

Frontal AxisFrontal Axis --45 to45 to --90 degrees90 degrees

QRS <120msQRS <120ms

rSrS pattern in II, II,pattern in II, II, aVFaVF (inferior leads)(inferior leads)

(c) 2000-2008 David Stultz, MD

LAFB + RBBBLAFB + RBBB

(c) 2000-2008 David Stultz, MD

Left Posterior Fascicular BlockLeft Posterior Fascicular Block Frontal Axis +/Frontal Axis +/--120 degrees (typically right axis deviation)120 degrees (typically right axis deviation)

QRS <120msQRS <120ms

RS pattern I,RS pattern I, qRqR pattern in II, II,pattern in II, II, aVFaVF (inferior leads)(inferior leads)

(c) 2000-2008 David Stultz, MD

QRS Duration <120ms

LAHB (LAFB)Severe LAD without explanation•Deep S waves in II, III, aVF•Frontal Axis <-45 to -60 degrees•Positive in I, Negative in aVF•Not explained by LBBB, LVH, inferiorinfarct

LPHB (LPFB)Opposite of LAFB, Rare•Usually Right Axis deviation•Negative in I, Positive in aVF•Positive in II, III, aVF•Not explained by RVH, anterolateralinfarct

Fascicular BlocksFascicular Blocks

Schedit, S. Basic Electrocardiography. CIBA-GEIGY Pharmaceuticals, USA, p 49.

(c) 2000-2008 David Stultz, MD

Fascicular Block CriteriaFascicular Block Criteria

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

An interesting caseAn interesting case

58 year old female admitted with syncope58 year old female admitted with syncope

Seen 2 weeks ago at previous hospital forSeen 2 weeks ago at previous hospital forsyncope, had negative workupsyncope, had negative workup

Describes someDescribes some clonicclonic motions during syncope,motions during syncope,having workup for seizureshaving workup for seizures

(c) 2000-2008 David Stultz, MD

Initial EKGInitial EKG

(c) 2000-2008 David Stultz, MD

About 2 hours laterAbout 2 hours later

(c) 2000-2008 David Stultz, MD

Overnight telemetryOvernight telemetry

Probably sinus rhythm with 2nd degree type 2 heart block

3rd degree heart block

(c) 2000-2008 David Stultz, MD

Rapidly progressive heart blockRapidly progressive heart block

Dual chamber pacemaker implantedDual chamber pacemaker implanted

During a portion of testing of pacemaker theDuring a portion of testing of pacemaker thefollowing day, only the atrial lead was pacedfollowing day, only the atrial lead was paced

(c) 2000-2008 David Stultz, MD

““FunFun”” EKGsEKGs

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

•Atrial Fibrillation•LAFB•Ashman phenomena•Long QTc

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

Atrial FibrillationLAFBRBBB

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

•Sinus rhythm•SA exit block (Wenkebach 3:2)

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

Sinus ArrythmiaWPW

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

Initiation of polymorphic VTLong-short-long cycle

(c) 2000-2008 David Stultz, MD

(c) 2000-2008 David Stultz, MD

•Atrial Fibrillation with WPW

(c) 2000-2008 David Stultz, MD