Comments on this ECG from the Web
response by
15 Sep 19956<ba01cacu@iqsnet.it>
The rhythm is BAV III. I would treat with a pacemaker.
response: I agree that this is third degree block and that it requires a pacer.
24 Oct 1996 CUPBEARER7@aol.com, UCSF Hospital
Looks like the lady is in complete heart block with regular p waves and a separate ventricular rhythm from at least 2 foci. I'm not a doctor, but I would guess maybe that an AV pacer might do the trick, and yes, I would admit her to the hospital. ( Oh yes, maybe you should check out what may be causing the block - meds etc., before any permanent pacer is placed.
response: Yes this is complete heart block. Note that the there are PVCs what look different but in fact are the same PVC recorded simultaneously in four leads. (V1, V2, V3 and II). Of great interest is the width of the PVC which looks wide in the last three leads but narrow in V1 and suggests that one must see a beat in several leads before one is sure that it is narrow. Sure you should check out other causes but it is a good idea to have temporary pacer in placer while you are looking up the list.
26 Oct 1996 <antemmar@pipeline.com>
the rythm is a 3rd degree A-V block; the patient should be treated a pacemaker; therefore she should be admitted.
response: Agree, but remember to place a temporary transvenous pacer or apply a transcutaneous pacer and test it as soon as possible. These patients are often unstable.
3 Nov 1996 <Marc.Neefs@Ping.be>
total a-v block, admit
response: Don't forget to place a temporary pacer
on an urgent basis!
29 Oct 1996 MMRCA5@aol.com
this is a lady in complete heart block with a ventricular escape beat. the hr being in the 30's, she will need to be admitted and have a pacemaker implanted.
response: Yes this is complete heart block but
the escape rhythm has a narrow width and is probably best described as a
nodal escape.
29 Oct 1996 Pieniek@aol.com
Sinus rhythm, with a junctional escape rhythm producing complete AV dissociation; and a ventricular beat which may represent a VPC or a VEB (ventricular escape beat). Yes, the patient needs admission. Metabolic and possible drug-induced etiologies must be excluded before placing any permanent type of pacemaker; A temporary pacemaker is indicated if the pt is hemodynamically unstable.
response: Agree that this is a junctional escape, it is interesting that there appears to be no disturbance of the sinus rhythm that is running at about 70/min. from this "junctional" rhythm which suggests that the block is in the retrograde direction too. Not all patients with block in the anterograde direction have block in the retrograde direction!
The early ventricular beat is a VP Cand not an VEB as it is premature and not an escape beat. You could hedge your bet by calling a VEB an ventricular extra beat.
The question of a temporary pacer is important. Although one always paces the unstable patient, it is probably best to pace all patients who present with complete block. They can suddenly become unstable, particularly those with wide complex escape rhythms. A real and significant danger is that the patient might aspirate if left asystolic for too long. In some cases a compromise for a "stable" patient is a transcutaneous pacer that is applied and proved to work with a right sided IJ catheter in place to ensure rapid access should it be required.
The disadvantage of a temporary pacer is mainly the risk of a pneumothorax or the loss of a side that could be useful for the permanent implant. (e.g. if the left subclavian is used for the temporary pacer wire) Secondly beware of the patient with intermittent heart block and a left bundle branch block. Your temporary wire might hit the right bundle on the way in and induce complete block with little or no escape!
31 Oct 1996 srampey@ix.netcom.com
Third degree heart block with a slow rate. ADMIT. PACER.
31 Oct 1996 "Dr.Aytekin Topcu" <atopcu@esk.net.com.tr>
a) The rhythm is complete heart block. b) Urgency temporary pacemaker insertion. c) Yes. If the rhythm is chronic, contemporary pacemaker ( Mode DDDR ) insertion needed.
response: Agree with A, B, and C.
The type of pacer is important. A DDDR is a dual chamber rate responsive pacer, and in some ways could be called a physiologic or universal pacer as it works with both chambers and provides rate response. The down side of a DDDR is mostly the cost and perhaps the longevity of the pacer. In this case one has to ask, why is the patient's sinus rate only about 70/min. Would you not expect a faster rate if the patient was in trouble?
In this case we choose a DDD without rate response. One could have also considered a single pass lead and a VDD pacer if the need for rate responsive atrial pacing is not considered necessary.
Curiously some patients have fast sinus rates which
persist after DDD implants.
31 Oct 1996 "Donna M. Roach" <roach@cgc.maricopa.edu>
Heart block. external pacing and hospital admittance
01 Nov 1996 <vikky@skyinet.net>
Complete AV block Permanent pacemaker Admit to hospital
01 Nov 1996 John Florit <rcvtrcds@erols.com>
1) 3rd degree Heart block 2) permanent pacemaker ( if no underlying treatable cause ) 3) Yes
2 Nov 1996
SCarey5452@aol.com
1. complete heart block. 2. dual chamber pacemaker. 3. Would put in hospital. Although she does have a narrow complex QRS as ventricular escape, I would not bet anyone's life on this. I would pace her the afternoon I met her.
response: Agree with the above. Acquired complete
heart block is not stable and your are correct in wanting to pace her immediately.
Note that the PVC affects the nodal escape rhythm and increases the interval
between the escape beats that surround it.
5 Nov 1996 "gmarcum" <gmarcum@indy.net> Henry County Memorial, New Castle, In
From what I see the Pt. is in 3rd degree block. yes I would put the Pt. in hospital and put a pacer in, do to the Pt. symptoms of the low heart rate. Question, why wasn't anything done the first time when the EKG produced the same thing.
response: The patient refused to come to hospital when she was seen by a cardiologist, and only after seeing an expert three days later did she accepted to be admitted to the ICU!
This is not a practice to be encouraged.
08 Nov 1996 Ken Hirsch <khirsch@itsa.ucsf.edu>
The rhythm is 3rd degree A-V block with a junctional escape. A PVB is also present. My treatment for this would be placement of a pacemaker. This patient would require admission to the hospital