A male in his 60's had hypotension. In the presence of the medics, he had syncope and they recorded this ECG:
He arrived in the ED alert with a BP of 80/60 and heart rate of 80. Here is the ED ECG:
There is no RBBB here. So there are two possibilities: the RBBB has resolved, leaving only LAFB. Or the escape on the prehospital ECG was coming from the posterior fascicle, making it a appear as if there is RBBB. The conduction would go through the posterior fascicle quickly (giving r-waves in inferior leads, and q-wave in aVL), then it would proceed to the anterior wall and the right ventricle through myocardium (giving S-waves in inferior leads, R-wave in aVL, R-wave in V1, and S-waves in V5 and V6.
Whether this prehospital ECG represents junctional escape with LAFB and intermittent RBBB, or left posterior fascicular escape, is impossible to say.
The patient had sepsis as a diagnosis.
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| There are no P-waves. So this is an escape rhythm. There is a large R-wave in V1 and S-waves in V5 and V6 (right bundle branch block morphology). There are small r-waves in II, III, aVF and deep S-waves. There is a small q-wave in aVL and large R-wave. So the morphology is of RBBB and LAFB. Since there is no P-wave, the complex represents an escape rhythm. It could be a junctional escape with RBBB and LAFB. The rate is typical of junctional escape. |
He arrived in the ED alert with a BP of 80/60 and heart rate of 80. Here is the ED ECG:
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| Sinus with left anterior fascicular block |
There is no RBBB here. So there are two possibilities: the RBBB has resolved, leaving only LAFB. Or the escape on the prehospital ECG was coming from the posterior fascicle, making it a appear as if there is RBBB. The conduction would go through the posterior fascicle quickly (giving r-waves in inferior leads, and q-wave in aVL), then it would proceed to the anterior wall and the right ventricle through myocardium (giving S-waves in inferior leads, R-wave in aVL, R-wave in V1, and S-waves in V5 and V6.
Whether this prehospital ECG represents junctional escape with LAFB and intermittent RBBB, or left posterior fascicular escape, is impossible to say.
The patient had sepsis as a diagnosis.
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