A. Atrial fibrillation
No. Atrial fibrillation is characterized by an irregular rhythm with no P waves. In this EKG the ventricular rhythm is regular and there seems to be P waves.
B. Second degree heart block, Mobitz type I (Wenckebach)
No. Mobitz type I heart block is characterized by progressive prolongation of the PR interval followed by a non-conducting P wave and the dropping of a QRS interval. There is no evidence of that in this EKG. However a longer rhythm strip would be appropiate to safely rule out Wenckebach block.
C. Right bundle branch block (RBBB)
No. Indeed right bundle branch block is present (QRS ≥ 0.12 s. and rSR’ pattern i lead V1). However this patient has a more serious conduction defect.
D. ST-elevation myocardial infarction (STEMI)
No. Though conduction defects and bradycardia may be caused by an acute myocardial infarction there is no ST segment elevation in this EKG. The inverted T waves in the precordial leads may however be due to recent infarction, but is more likely repolarisation abnormalities due to a conduction defect.
E. Third degree (complete) heart block
Yes! In complete heart block the conduction from the atria is completely blocked. The atria and ventricles contract independently, which is reflected on the EKG as independent P and QRS activity. The P waves in this EKG are difficult to spot, but are most easily seen in V1-V2 – note that they may be hidden in the QRS complexes or the T waves. The ventricles are activated from a ventricular focus (broad QRS complexes). The ventricular focus is firing significantly slower than the sinus node, which is the reason to the slow rate. The patient likely suffered loss of consciousness due to transient ventricular stand-still (Stokes-Adams attack). See more on complete heart block in the library.
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{ 8 comments… read them below or add one }
it is a very interesting and challenging ecg strip for me, it really helps me to build up my ecg knowledge before my ecg examination. thanks
I was not able to recognize any p-waves in the EKG. It looks pretty flat to me.
No elevation noted
the p waves are really hard to see. i have a magnifier on my screen which is how i was able to see them. the thing i noticed, however, was that the ventricular rate was about 30bpm. as there wasn’t a ventricular escape rhythm in the options, and in my experience a right bundle branch block (which is seen in lead v1 and v2) does not generally cause a sudden loss in consciousness, but a third degree block does, i chose the 3rd degree. There was no ST segment elevation, and Wenchebach is really really distinctive.
It would be nice if you could actually see the P waves, what you are calling p waves are flat…. Maybe put up a different strip of a 3rd degree…. With better P waves
The p waves are clear to see if you know where to look. Anytime you are having trouble seeing p waves in Lead II, look to V1 and V2. These two leads have a better view of the atrial activity.
Rate: 33
Rhythm; regular
widened QRS complexes , non dectecable p waves or hidden with in QRS complex
Left Axis deviation
Right ventricular Hypertrophy
Significant Q waves in I, II,AVL, V 4,5,6
ST depression: V2,3,4,5 Slurred S waves in II, AVL, AVF, V3,4,5
DX: Idioventricular rhythm (33bpm) Lateral and posterior wall infarct and anterior hemifasicular bundle branch block
all not very good for this patient
P waves are close to impossible to see