tag:blogger.com,1999:blog-549949223388475481.post2077049059829050674..comments2024-03-26T22:42:04.176-05:00Comments on Dr. Smith's ECG Blog: Wide Complex Tachycardia; It's really sinus, RBBB + LAFB, and massive ST elevationUnknownnoreply@blogger.comBlogger29125tag:blogger.com,1999:blog-549949223388475481.post-24342741834058046872019-08-04T10:04:52.390-05:002019-08-04T10:04:52.390-05:00You can, or CAN'T? See the annotated image wh...You can, or CAN'T? See the annotated image where the arrow points to the P-wave.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-37109298660270251582019-07-30T14:42:15.357-05:002019-07-30T14:42:15.357-05:00I can really make out the P wave, any help?I can really make out the P wave, any help?Areyoumehttps://www.blogger.com/profile/17657260699238126115noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-16477309768544306232019-04-05T14:14:52.819-05:002019-04-05T14:14:52.819-05:00I shouldn't have written "easy." It...I shouldn't have written "easy." It is not easy. But at least there is an inflection point in V1 and 2 of the leads beneath it which strongly suggests the J-point (end of QRS and beginning of ST segment)Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-29639728664021324742019-04-04T20:24:22.818-05:002019-04-04T20:24:22.818-05:00I'm a little mystified about what makes the en...I'm a little mystified about what makes the end of the QRS "easy" to find in V1? As this is the key step in being able to assess the ST segment, I'd love to known any tips for confidently identifying the end of the complex. Albyhttps://www.blogger.com/profile/15598108632807387610noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-3119759941307433752018-11-27T11:22:34.157-06:002018-11-27T11:22:34.157-06:00Mr Smith thank u so much.Mr Smith thank u so much.Anonymoushttps://www.blogger.com/profile/15768776820007993271noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-47143881739776591382017-10-11T16:46:05.071-05:002017-10-11T16:46:05.071-05:00No. It is RBBB. There is no S-wave in I because o...No. It is RBBB. There is no S-wave in I because of terminal QRS distortion from the ST elevation.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-39969187034150239412017-10-05T15:36:40.340-05:002017-10-05T15:36:40.340-05:00How about calling it IVCD?? as there is no S wave ...How about calling it IVCD?? as there is no S wave in lead 1 and from what i have read a classical RBBB has has wave in lead 1. or is it because STe in 1 causes the loss of s wave??.. Any comments???<br /><br />thanks....MGhttps://www.blogger.com/profile/06233522417024317416noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-31917783870477940882016-07-08T08:20:07.220-05:002016-07-08T08:20:07.220-05:00Definitely sinus. P-waves are present and have th...Definitely sinus. P-waves are present and have the exact correct morphology for P-waves. This is a classic EKG of a sick patient with proximal LAD occlusion, RBBB, LAFB, and pseudo VT. I have seen it many times. Memorize this morphology.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-3429650249821268902016-06-21T19:38:10.568-05:002016-06-21T19:38:10.568-05:00Are you sure this isn't VT? AVR and V6 look li...Are you sure this isn't VT? AVR and V6 look like VT. You didn't respond to Nick Adams. The p waves could be retrograde. It is slow for VT if he was having an acute MI. Do you know what happened with this patient?stepchttps://www.blogger.com/profile/16416748061701051683noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-60216401685579463202015-03-29T11:59:08.733-05:002015-03-29T11:59:08.733-05:00If you're not sending him to the cath lab anyw...If you're not sending him to the cath lab anyway, and you think these are just post arrest changes, then wait 10 minutes and get another. However, with RBBB and LAFB, these are unlikely to be post arrest and much more likely to be Left Main or proximal LAD. Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-52624509111375837882015-03-29T11:31:32.461-05:002015-03-29T11:31:32.461-05:00What about post arrest ECGs? I have seen quite a f...What about post arrest ECGs? I have seen quite a few patients with nasty looking ECGs, broad complexes, ST changes early after ROSC (especially prolonged arrests) that then resolve on repeat traces. <br /><br />In this case even if I thought it was VT (which I may well in the heat of the moment) I would be very suspicious of STs V3-4, I, aVL. Also a 51M post arrest is probably going to the lab anyway, especially if CP first. Anonymoushttps://www.blogger.com/profile/16888292983934728491noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-37126315400010978362014-08-13T08:56:29.078-05:002014-08-13T08:56:29.078-05:00The impulse travels fast only down the posterior f...The impulse travels fast only down the posterior fascicle, then slowly to the area that would normallly be depolarized by the anterior fascicle and the right bundle. So LAFB is only a partial LBBB.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-91855921638977082712014-08-13T08:54:12.273-05:002014-08-13T08:54:12.273-05:00I'm sorry I don't understand the questionI'm sorry I don't understand the questionSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-71929401707361732132014-08-09T16:43:12.496-05:002014-08-09T16:43:12.496-05:00Also forgot too ask a important question if a ECG ...Also forgot too ask a important question if a ECG Shows a Rbbb & Lafb.will it show up every time on a ECg because he told me he didn't see it on the New ECG test Or do ECG change conitiously ? Thanks.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-65177211190788615682014-08-09T16:37:32.304-05:002014-08-09T16:37:32.304-05:00I ask my cardio a question about my Rbbb & Laf...I ask my cardio a question about my Rbbb & Lafb he told me that this meant that the electrical flow was just passing thru the left bundle but the problem is I never had a Lafb Finding combination on my report And also with just a rbbb wouldn't it be conducting thru the Left side anyways. So this finding Is Separate from just a Rbbb Right ? Aren't they 2- Separate findings ? and if So why is he acting as though its still Just a Rbbb. And not a Bifascicular Conduction problem .they haven't said their was a MI involved or blocked atery So I still be Concerned? Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-6280680742743408672014-07-25T23:27:54.219-05:002014-07-25T23:27:54.219-05:00Any new bifascicular block (1. LBBB (LPFB + LAFB) ...Any new bifascicular block (1. LBBB (LPFB + LAFB) 2. RBBB + LAFB 3. RBBB + LPFB) in the setting of MI, especially with lengthening PR interval, can lead to complete heart block. So one must be vigilant.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-52406428819084592002014-07-25T22:53:26.017-05:002014-07-25T22:53:26.017-05:00Maybe I said it wrong above it appears I put lab&g...Maybe I said it wrong above it appears I put lab>I meant my report stated Rbbb with a LAFB this makes a dfference ? Right is this a serious conduction problem ? Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-50401130964202099792014-07-21T07:08:06.744-05:002014-07-21T07:08:06.744-05:00Bundle branch blocks and AV block (Mobitz is a typ...Bundle branch blocks and AV block (Mobitz is a type of AV block) are entirely differentSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-2747636261849166522014-07-20T16:16:08.518-05:002014-07-20T16:16:08.518-05:00I was diagnosed with rbbb& Lab on my ECG repor...I was diagnosed with rbbb& Lab on my ECG report is this Consisdered a type 2 mobitz heart block? Since these originate are in his bundle area.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-3863374566838536812012-05-05T23:30:51.716-05:002012-05-05T23:30:51.716-05:00I wish someone would make a work sheet with the fo...I wish someone would make a work sheet with the following questions answered:<br /><br />1) False positive MI- Early repol and LVH and pericarditis<br /><br />2) False Negative MI- Left bundle branch block, Pacer, <br /><br />And then under those someone could go through the criteria for each to help distinguish between MI. <br />Also i still cant figure out where fasicular blocks and right bundle branch and fasicular + right bundle branch block come into the picture!<br /><br />The problem with The fasicular blocks and the right bundle is really annoying because those are the ekgs i have the most problems with. <br /><br />Any advice?brownmiesterhttps://www.blogger.com/profile/12949984829309227383noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-68116711333223326522010-11-30T07:52:25.668-06:002010-11-30T07:52:25.668-06:00This is a very nice example of a VT mimicer. I be...This is a very nice example of a VT mimicer. I beleive this to be a VT mimicer because of the P waves that procede every QRS. If I look at this 12 lead and did not notice the P waves, I would convince myself that this was truley VT. I would call this VT for a few reasons:<br /><br />1) Pathological LAD is no help in calling VT. ERAD would be better.<br /><br />2) Although you say the patient has a rsR' type morphology in V1. the r wave is so small, it's almost nonexistent. Therefore, the morphology of V1 is positive in a, not so great, "Firemans Hat" appearance.<br /><br />3) The ventricular depolarization transitional zone is @ V4, which is normal......no help.<br /><br />4) V6 is negative. This is the #1 detail that would cause me to believe this is Ventricular in origin.<br /><br />Since there a P waves, this can't be VT. <br /><br />I do have a question though.<br /><br />If the impulse originates in the SA node and the impulse is traveling to the ventricles using the normal patways (with the exception of the RBBB), how is V6 negative? The positive pole of V6 is at the base of the LV....it should be positive....even in a RBBB.<br /><br />Could these "P-waves" actually be U-waves, therefore it is VT?<br /><br />HELP......lolNick Adamshttps://www.blogger.com/profile/15508113117076413020noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-30639540736232166442010-11-16T22:26:48.670-06:002010-11-16T22:26:48.670-06:00You are correct that the patient is at some riskk ...You are correct that the patient is at some riskk of complete heart block, but is not in block now. In fact, the PR interval is short which makes any imminent progression to complete block very unlikely.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-70083884342263669502010-11-16T22:24:51.892-06:002010-11-16T22:24:51.892-06:00Thank you. The upright lead I is due, as the prev...Thank you. The upright lead I is due, as the previous posteer accurately pointed out, to the coexistent Left anterior fascicular block.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-69169256063894315712010-11-16T22:22:03.676-06:002010-11-16T22:22:03.676-06:00As for biphasicular blocks being "more import...As for biphasicular blocks being "more important" than the STEMI, make sure you take Multi Lead "MEDIC" in context. He is teaching what you as a medic should look for and do, but not necessarily what the patient ultimately needs. You can very effectively manage a heart block in an ambulance with transcutaneous pacing and drugs. The STEMI needs PCI in a cath lab. So for a medic, absolutely manage the complete heart block if it occurs and get him to a cath lab ASAP. But the STEMI is the ultimate (and MUCH bigger) problem. A biphasicular block is a warning sign of the POTENTIAL for a problem (a 3rd degree block). A STEMI is a real problem.Jasonnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-44386890881561531392010-11-16T21:59:11.676-06:002010-11-16T21:59:11.676-06:00Lead I is actually biphasic. The terminal S cause...Lead I is actually biphasic. The terminal S caused by the RBBB in lead I is masked by the massive ST elevation. Lead I will not be purely upright in a RBBB even with a LAFB because you will always have a late rightward depolarization.Anonymousnoreply@blogger.com