56 year old male presents with acute onset of sudden central chest pain radiating down both arms with pins & needles sensation, patient found sitting in chair.
This p/t has had 4 previous MI's with stents fitted, p/t stated that pain feels different from previous MI's. Patient stated he had the feeling of impending doom.
This p/t has had 4 previous MI's with stents fitted, p/t stated that pain feels different from previous MI's. Patient stated he had the feeling of impending doom.
Skin: dry, look well perfused (pink)... but had been on oxygen for some time given by the responder, before the arrival of the crew...
Pain score 08/10
No nausea or vomiting
Past medical history:
Hypertension
Past medical history:
Hypertension
Previous MI's
Angina
Vital signs:
BP: of 123/49 (Low for this p/t)
HR: 72
RR: 22
SpO2: 99%, 100 on O2 via NRB mask @ 15 LPM
BM: (blood sugar) 5.4 mmol/l
Temp: 36.7
Lead III strip above and Pre-hospital 12-lead ECG
Ventricular rate: 80
PR interval: 120 ms
QRS Duration: 166 ms
QT/QTc: 418/482 ms
P-R-T axes 13 72 -3
Emergency Department 12-Lead ECG
Please comment on the features of this ECG:
What findings do you see ?
For experienced members in cardiology, please use this ECG as a teaching tool, passing on your knowledge and experience to others.
Complete RBBB with inferior M.I. with Right Axis Deviation.
ReplyDeleteRegular sinus,right axis deviation,AV Block,3rd degree with Pics(post myocardial infaction).
ReplyDeleteWhy inferior infarct? Can someone please explain?
ReplyDeleteST Elevation in lead III and aVF.
ReplyDeleteI think what looks like STE is just the RBBB pattern. If you map your J points, none are truly elevated.
ReplyDeleteRBBB plus inferior IM, or aneurysm concomitant to prior IM. Also it has left posterior fascicular hemiblok
ReplyDeleteI think what appears to be RBBB is infact STE. Please note the narrow QRS in II and V5-6.
ReplyDeleteAnonymous said...
ReplyDeleteI think what appears to be RBBB is infact STE. Please note the narrow QRS in II and V5-6.
I disagree, lead II is not as narrow as it first appears. Please map J point from leads I and III to find true ST-segment.
ok
ReplyDeletei think this is inferior STEMI it is not as it appears RBBB simply look at avr and lead 2 and v4-to 6 all show narrow complex so it is not bundle block it is just inferior mi which with the reciprocal of lat leads i think dt to this elevation in avr vi v2 maybe also rt ventricular infarction so we should check on it and make rt leads and posterior leads too
This is what I am seeing. I am not saying I am right, but it makes sense given that there is an isoelectric ST-segment visible in some leads and obvious rSR' complex in some leads.
ReplyDeletecheck out this: http://s12.photobucket.com/albums/a245/adam954/?action=view¤t=Jpoint.png
The black lines represent the J point placement, and the Blue lines represent the isoelectric line. Some have stated that there are wide complexes in some, but narrow complexes in other leads. I challenge that theory, because it would make more sense that some complexes are appearing narrow, but are truly wide. Also notice the appropriate T wave discordance for a RBBB.
I do, however, note ST-depression in v6 and biphasic T waves indicating possible Wellen's phenomenon, which coincidently, could mean impending doom.
ReplyDeleteRBBB, no STEMI, All QRS have the same duration, some leads do not APPEAR to have the same duration but that is lead variation, not reality. Compare leads directly above and below to help determine J-point. A. Thompson is right.
ReplyDeleteThe two twelve leads appear different which could just be because of treatment. I am not saying that I am right, but this is what I think. Normal sinus rhythm with RBBB, the monitor gave us QRS of 166ms. Normal axis so no hemiblock. ST elevation in inferior wall leads with reciprocal changes in lateral wall leads. 2nd 12 lead QRS is at 96ms which isn't contingent with a RBBB. Still normal axis, and still inferior wall elevation and depression in lateral wall leads
ReplyDeleteAfter looking at lead one again I'd say this is an indeterminate BBB. Either way, I do note the changes between 12-leads, mostly in the precordial R-wave progression. Is it possible that this is from two different placements. prehospital vs. ER?
ReplyDeletehumbly: RBBB without ST elevation
ReplyDeleteslurred S in I and V6 is a reliable way to determine RBBB in a supraventricular rhythm with wide QRS.
remember, the true QRS duration in a 12-lead is ALWAYS the widest QRS you can find in the underlying baseline rhythm in all of the leads.
because of the way electrodes pick up signals, if a part of the QRS is close to isoelectric in some leads, then those QRSs aren't going to appear in its true width.
Based on clinical presentation - hypotension + ecg - inferior wall MI with RV infarct. RBBB in this case is one of the conduction abnormality associated with RV infarct. Would suggest if you have a hypotensive patient with inferior wall MI get a V3R or VR4.
ReplyDeleteI think this p/t has
ReplyDelete- normal sinus rhythym
- complete RBBB (rSR pattern on V1&V2)
- inferior STEMI (Q on II,III,aVF, STE on II, aVF)
- left posterior fasicle hemiblock (RAD, rS on I, avL; qR on II,III,aVF)
with Right axis deviation
the two different ECG (prehospital&ER) showed noticeable progressive turn of hiperacute infact to acute infarct (notice the Q on inf. leads)