A weekly ECG / EKG review blog looking at some interesting ECG's from the world of Emergency Medicine.
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Friday, 14 December 2012
ECG of the Week - 17th December 2012
This ECG is from 46 yr old man presenting with several months of exertional dysponea and fatigue. At the time of review his BP was 110/60 mmHg. Thoughts ? Differential diagnosis ?
Click to enlarge
Thanks to Dr Shakeeb Razak for sharing this interesting case.
Sinus rhythm @ approx 85 bpm. AV dissociation with no signs of any AV conduction, so complete heart block. QRS #4 arrives a little bit early, but it's seemingly unrelated to any p-waves and probably just physiologic variation. Junctional rhythm at approx 49 bpm.
In terms of workup, he'll probably buy an echo to look for structural or wall motion abnormalities, but I'm not seeing much to guide me on the ECG.
A medication and supplement Hx will be important for ruling out a tox cause.
I suppose electrolytes will also be necessary, but I'm not thinking they're the culprit here.
He'll probably also get an infectious workup to look for myocarditis or Lyme (and then there's the real rare things around here like Chagas).
Based on the duration of the symptoms, I can't imagine many causes amenable to medical therapy, so he'll probably be getting a pacer.
The final option is that he's been in a congenital complete heart block his whole life without knowing it, and it's either just now becoming symptomatic or there's actually another cause for his fatigue and this is just a red-herring.
That should cover almost everything ever... Based off the presentation and lack of other ECG findings, I'm thinking it's either infectious or a congenital, but that's really extrapolating a lot off of a small amount of info.
Rhythm: sinus rhythm with a complete heart block and a junctional escape. Some ventriculophasic sinus arrhythmia is present and minor variations in junctional rate exist as well.
Sinus rhythm @ approx 85 bpm.
ReplyDeleteAV dissociation with no signs of any AV conduction, so complete heart block.
QRS #4 arrives a little bit early, but it's seemingly unrelated to any p-waves and probably just physiologic variation.
Junctional rhythm at approx 49 bpm.
In terms of workup, he'll probably buy an echo to look for structural or wall motion abnormalities, but I'm not seeing much to guide me on the ECG.
A medication and supplement Hx will be important for ruling out a tox cause.
I suppose electrolytes will also be necessary, but I'm not thinking they're the culprit here.
He'll probably also get an infectious workup to look for myocarditis or Lyme (and then there's the real rare things around here like Chagas).
Based on the duration of the symptoms, I can't imagine many causes amenable to medical therapy, so he'll probably be getting a pacer.
The final option is that he's been in a congenital complete heart block his whole life without knowing it, and it's either just now becoming symptomatic or there's actually another cause for his fatigue and this is just a red-herring.
That should cover almost everything ever... Based off the presentation and lack of other ECG findings, I'm thinking it's either infectious or a congenital, but that's really extrapolating a lot off of a small amount of info.
Rate: atria 75 bpm, ventricles 45 bpm
ReplyDeleteRegularity: P-P regular (some ventriculophasic shortening is noted in the first P-P intervals enveloping the QRS), R-R regular (excepting 3rd and 4th R-R are shorter)
P-waves: sinus (rounded, upright, symmetric)
PRi: no fixed relationship (even extended to jumping a P-wave)
QRSd: narrow, bundle branch conduction appears intact
Axis: normal, 60 deg
QTi/QTc: normal, 362 ms Bazett's
Q-waves: none noted
ST/T-waves: unremarkable
Rhythm: sinus rhythm with a complete heart block and a junctional escape. Some ventriculophasic sinus arrhythmia is present and minor variations in junctional rate exist as well.