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Introduction
• Introductory Slide explaining purpose and navigation
• A 71 year old female with generalized fatigue (can we add a few more descriptors here)?
• Presents with the following ECG
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ECG # 2
Criteria for major
diagnosis
Causes
Mimickers
Management
Other similar examples
Button to show answer, diagnostic criteria, +/- teaching
points
Clinical Vignette
Diagnostic criteria index
07 Sinus rhythm21 AV junctional escape complexes33 AV Block, 3°
71 year old female with generalized fatigueCauses
Mimickers
Management
Other similar examples
Criteria for major
diagnosis
Diagnostic criteria index
Diagnostic Criteria: 33 AV Block, 3°• Atrial and ventricular rhythms independent of each other (AV dissociation)• Variable PR intervals• Constant PP and RR intervals; A rate usually faster than V rate• Ventricular rhythm maintained by junctional or idioventricular escape
rhythm
71 year old female with generalized fatigue
Causes
Mimickers
Management
Other similar examples
Criteria for major
diagnosis
Diagnostic criteria index
07 Sinus rhythmRegular Sinus Rhythm Atrial Rate 75Notice the constant P-P intervals which are not altered by ventricular QRS complex.
Causes
Mimickers
Management
Other similar examples
Criteria for major
diagnosis
Diagnostic criteria index
71 year old female with generalized fatigue
21 AV junctional escape complexes Narrow QRS complex beats; rate usually 40-60 per minuteThis is a secondary phenomenon in response to high grade AV block.
There is no relationship of the QRS complexes to the P waves.
Causes
Mimickers
Management
Other similar examples
Criteria for major
diagnosis
Diagnostic criteria index
71 year old female with generalized fatigue
Causes
• MI• Drug toxicity (digoxin, beta-blockers, calcium
channel blockers)• Degeneration of conduction system• Post-cardiac surgery• Infiltrative diseases• Infective endocarditis (esp aortic valve)• Lyme disease
MimickersDiagnosis Differentiating features
1st degree AV block • Constant PR interval
2nd degree AV block- Type I • Constant PP interval• PR interval progressively lengthens until one QRS complex is not conducted (“dropped beat”)• Appearance of “grouped beating” on rhythm strip
2nd degree AV block – Type II • Constant PP interval• PR interval is constant EXCEPT for non-conducted P wave (“dropped” QRS)
AV dissociation • Atrial and ventricular rates are different (atrial rate may be slower or faster) • PP intervals constant• RR intervals constant
Management
• Continuous monitoring of heart rhythm• Discontinue drugs with AV node blocking effect; if
taking digoxin, measure serum level• For suspected drug toxicity, consider counter-active
medications• If symptomatic or concern for clinical/hemodynamic
worsening, consider transcutaneous or transvenous pacing; may temporize with dopamine, dobutamine, isoprotenernol IV
• If congenital, evaluate response to exercise
Diagnostic criteria: 3rd Degree AV Block
• Atrial and ventricular rhythms independent of each other (AV dissociation)
• Variable PR intervals• Constant PP and RR intervals; A rate usually
faster than V rate• Ventricular rhythm maintained by junctional
or idioventricular escape rhythm
Index of diagnostic criteria
• AV block, 1st degree• AV block, 2nd degree, type 1• AV block, 2nd degree, type 2• AV block, 3rd degree• AV dissociation…
