# Lets play "guess that EKG"



## 281mustang (May 22, 2012)

I have five. Here they are:

1.






2.





3.





4.





5.





Gracious.


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## Aidey (May 22, 2012)

I'm on my phone, which makes it really hard to see details. But 1 is a lateral MI, 3 is a LBBB and 5 is A Flutter, looks like it is varying between 2:1 and 3:1.


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## Hunter (May 22, 2012)

281mustang said:


> I have five. Here they are:
> 
> 1.



Slight St elevation in II avf v4 v5 v6?



281mustang said:


> 2.


Slight depression in II and afv?



281mustang said:


> 3.



LBBB?



281mustang said:


> 4.



Having trouble with this one, maybe a borderline 1st degree block? kinda hard to tell on my phone.



281mustang said:


> 5.
> 
> 
> 
> ...


Looks like AFlutter


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## Scott33 (May 22, 2012)

Aidey said:


> 1 is a lateral MI



Where are the reciprocal changes? 

Looks like pericarditis.


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## Scott33 (May 22, 2012)

Hunter said:


> Having trouble with this one, maybe a borderline 1st degree block



And RBBB, and possibly left posterior hemiblock. In which case you will have a bi-fascicular block


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## britmedic (May 22, 2012)

Scott33 said:


> And RBBB, and possibly left posterior hemiblock. In which case you will have a bi-fascicular block



And 1st degree heart block = tri-fascicular block


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## Scott33 (May 22, 2012)

Not always...



> _As noted the EKG pattern consisting of fascicular block, right bundle branch block and first degree heart block is not always caused by trifascicular block. This pattern could potential be due to “true” first degree heart block combined with bifascicular block, thus with one of the intraventricular fascicles being fully intact. An absolute diagnosis of trifascicular block therefore require electrophysiological examination_



http://www.ekginterpretation.com/library/trifascicular-block/



> _The term trifascicular block is also confusing since involvement of the right bundle branch and both fascicles of the left bundle branch would be manifested as complete heart block. Thus, trifascicular block is most often inaccurately applied to patients with bifascicular block and prolongation of the PR interval._



http://www.uptodate.com/contents/course-and-treatment-of-chronic-bifascicular-block

I get what you are saying though. It's 3 blocks, but not necessarily 3 blocked fascicles.


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## Hunter (May 22, 2012)

Pardon my ignorance what's a tri-fascicular block?


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## britmedic (May 23, 2012)

Scott33 said:


> Not always...
> 
> I get what you are saying though. It's 3 blocks, but not necessarily 3 blocked fascicles.



I take a bow before superior knowledge. Will take a look at links when I'm more awake and compare with my books. Back later


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## jwk (May 23, 2012)

britmedic said:


> And 1st degree heart block = tri-fascicular block



That statement is incorrect.  First degree heart block has nothing to do with fascicular blocks.

A "fascicular block" refers to a block in either the RBBB, LAFB, or LPFB.  A bifascicular block refers to a block of the RBBB and one of the left-sided fascicles.  As someone else has pointed out, a tri-fascicular block would be a total heart block. 

A bifascicular block indicates the conduction system is already damaged significantly.  It's like firing on only one cylinder out of three - not a good thing if that third cylinder goes out.


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## JakeEMTP (May 23, 2012)

It might be a good idea to remove the name of the hospital and the tech's initials before posting examples. Even without the name of the patient, some places may not want to give the impression parts of their medical records are available to be posted on a public forum unless it is identified as teaching only and then they may reserve the right to their materials and usage.


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## Christopher (May 23, 2012)

1. Early Repol versus Pericarditis. Fishhooked J-points, PR-depression in II/PR-elevation in aVR, diffuse ST-E.

2. Maybe a PE (S1Q3T3), maybe ACS. I'd trend this patient's ECG's and get a posterior view.

3. I pretty much agree with the monitor. 1AVB and LBBB. Would trend to see if the ST-E changes in the right precordials, otherwise I'm unimpressed.

4. RBBB, inferior axis, 1AVB; maybe "bifasicular block". If this patient was in for a syncopal episode I'd pay attention to their rhythm pretty closely. V2/V3 have odd lead placement I'll bet.

5. Again, I feel pretty comfortable with the monitor on this one. Atrial flutter with a variable block.


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## ZootownMedic (May 23, 2012)

Hunter said:


> Pardon my ignorance what's a tri-fascicular block?



1.) 1st Degree AVB (prolongnation of PR interval > 0.2 secs)
2.) RBBB
3.) Either a Left Posterior or Left Anterior fasicular block.

-ALL AT THE SAME TIME


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## Hunter (May 24, 2012)

SmokeMedic said:


> 1.) 1st Degree AVB (prolongnation of PR interval > 0.2 secs)
> 2.) RBBB
> 3.) Either a Left Posterior or Left Anterior fasicular block.
> 
> -ALL AT THE SAME TIME



So... someones AFU...


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## TatuICU (May 24, 2012)

SmokeMedic said:


> 1.) 1st Degree AVB (prolongnation of PR interval > 0.2 secs)
> 2.) RBBB
> 3.) Either a Left Posterior or Left Anterior fasicular block.
> 
> -ALL AT THE SAME TIME



No.  Once again a misuse of the nomenclature.


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## Brandon O (May 24, 2012)

Trifascicular block is a slang term which is not useless but, as we're seeing, is not universal enough to use without knowing your audience.

I believe Bob Page may have popularized it among EMS?


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## Ecgg (May 24, 2012)

jwk said:


> That statement is incorrect.  First degree heart block has nothing to do with fascicular blocks.
> 
> A "fascicular block" refers to a block in either the RBBB, LAFB, or LPFB.  A bifascicular block refers to a block of the RBBB and one of the left-sided fascicles.  As someone else has pointed out, a tri-fascicular block would be a total heart block.
> 
> A bifascicular block indicates the conduction system is already damaged significantly.  It's like firing on only one cylinder out of three - not a good thing if that third cylinder goes out.



That is exactly on point! I made a quick picture illustration to show the differences in various blocks.






http://tinypic.com/r/280nm9v/6

hemi-
A prefix meaning "half," as in hemisphere, half a sphere.

In cardiology this means:
Hemi means half and block means a block. Thus when you have a hemiblock you have a half that is blocked.

Hemifascicles are the anterior located at the front and the posterior
located at the back. These fascicles make up the left bundle branch conduction pathway. (See diagram)


In the heart you can have various blocks (or a combination of thereof) 

SA blocks Sino-Atrial blocks: (blocks at SA node)
Sinus pause
Sinus arrest
Sinus block
All associated with Adam stokes syndrome.

AV blocks Atrio-Ventricular blocks (blocks at the AV junction)
1 degree HB
2 nd degree type 1 and 2
3 rd degree complete HB (Heart Block)

Intra-Ventricular blocks (Means blocks inside the ventricles)
RBBB Right Bundle Branch Block
LBBB Left Bundle Branch Block (here both fascicles are blocked)
Hemiblocks: Anterior hemifasicle block and Posterior hemifascicle block

If you have 2 blocks out of these 3 categories pick and choose any
then it's a severe degree of block. The term bifascicular however only refers to Intra-Ventricular Conduction system if you want to be specific and the quote above details the combinations. However all these EKG changes need to be taken into account with patient presentation, vital signs, chief complaint etc... A 12/15 Lead EKG NEVER RULE OUT AN AMI!


Disregard any spelling typos.


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## Christopher (May 29, 2012)

Brandon Oto said:


> I believe Bob Page may have popularized it among EMS?



Grrr: "if you say 'block' more than 17 times, lead II has no dice." Or something catchy like that!

But to stir the pot you could have a 1AVB due to problems below the AVN. Say RBBB with some slowing in the left bundle branches side of the His.


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