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Patient: 75 y/o male. Medical history and anamnesis unknown. Experienced several Adams-Stokes episodes and his wife called EMS. This is a prehospital 12 lead from the LP12.
ECG description:
- No P-QRS relationship. Independent pacemakers.
- Atrial rate is 125 bpm. Ventricular rate is close to zero.
- No escape rhythm present
- P axis is normal at 60 degrees
Discussion:
This is ventricular standstill. The underlying rhythm is sinus tachycardia at 125 bpm, but there is complete failure of the impulses to reach the ventricles. The first QRS complex is of junctional origin, the second is from the ventricles, probably the right ventricle. Unfortunately, this 6 second recording does not tell whether this is an escape rhythm or just single beats.
October 3, 2009
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Patient: 84 y/o woman with no cardiac history. No syncopal episodes. Generally fatigued and “feeling a bit dizzy” the last week. Has not noticed any tick bites or had any symptoms of borreliosis. Comes walking into the ER and complains about tiredness. Initial BP is 180/80. SAT 96% w/o oxygen, RF 16/min. No pain/nausea.
ECG description:
- Narrow Complex Bradycardia
- More P waves than QRS complexes
- No association between P waves and QRS complexes
- Atrial rate 82 bpm
- Ventricular rate 39 bpm
- Axis at approx. 30°
- T wave inversion in leads V1-V3, III, aVF
ECG interpretation: Third Degree / Complete Atrioventricular Block with Junctional Escape Rhythm.
ECG comments: All P waves are blocked from leaving the AV Node. There is regular and normofrequent atrial activity, probably sinus, but none of the atrial impulses gets propagated further down the conduction system. The atrias and ventricles are acting independently. This is AV dissociation and produces a complete heart block. As the atria and the ventricles are now oblivious of each other, they run at different speeds. This is because they are independently paced. The ventricles are being paced from an ectopic focus, resulting in a rate of 39 bpm. Considering this rate and the narrow configuration (80ms) of the QRS complexes, the ectopic focus is most likely junctional. Usually, ectopic rhythms originating around the AV Node will pace from ca. 40-60 bpm.
Treatment: Isoprenaline and permanent pacemaker
CLICK TO SEE LARGER: Ladder diagram for lead V2, showing atrial impulses being blocked in the AV Node, and a nodal ectopic impulse generating an escape rhythm.
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January 4, 2009