Monday, April 6, 2009

Right BBB and Bigeminy, with Anterior STEMI

This is from a 53 year old male smoker with chest pain.
Here is the initial EKG:
There is grouped beating, in couplets. Both complexes in each couplet are wide. the first complex in each couplet is preceded by a p-wave. If you look at the first of each couplet in V1 and V6, they have RBBB morphology. So this is bigeminy with RBBB. Obviously, the ST and T wave are very abnormal, with huge ST elevation due to LAD occlusion.

In the inferior leads, there appears to be ST elevation in both complexes, but this is not so: what appears to be STE is really just a prolonged QRS.

Thanks to Dave for this case: http://tassieparamedic.blogspot.com/

5 comments:

  1. You have a nice blog
    I invite you to mine:
    (Broken heart syndrome)
    http://tabibqulob.blogspot.com/2009/04/cardiocerebral-resuscitation-ccr.html

    ReplyDelete
  2. sinus bradycardia with bigeminy PVC, retrograde atrial capture, RBBB, anteroseptal and inferolateral myocardial injury. definitely LAD occlusion

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  3. There is indeed LAD occlusion, and lateral injury, but NO inferior injury. What appears to be ST elevation in inferior leads is only a prolonged QRS. There is indeed minimal STE in II and aVF, but there is, in fact, reciprocal ST depression in lead III.

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  4. But there is still RBBB with concordant T waves in the inferior leads, doesn't that speak for ischemia, too?

    ReplyDelete
    Replies
    1. The limb lead ischemia is in I and aVL, with some subtle ST elevation. (anterolateral STEMI from proximal LAD occlusion). In RBBB, T-waves are often concordant with the upright R-wave. They are, however, usually discordant with the wide S-wave (or R' wave in V1-V3).

      Delete

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