Bundle-

Bundle-branch blocks
Most common electrocardiogram (ECG)
Understanding the
„
abnormality

12-lead ECG, part II „ Appears as a wider than normal QRS

complex

„ Occurs when one of the two bundle

branches can’t conduct the impulse

„ Most common cause: ischemic heart 2

disease

Right bundle-
bundle-branch block (RBBB) Left bundle branch block (LBBB)
„ Impulse conduction to right ventricle is „ Electrical impulses don’t reach left
blocked side of the heart

„ Examine lead V1 to
identify RBBB „ QRS wider than 0.12 second

„ ECG show delayed or positive R wave „ Key to recognizing LBBB

is a wide downward
„ Key identifier is QRS complex wider than S wave or rS wave in
0.12 second, with positive R wave in V1 leads V1 and V2
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 What do you think? What do you think?

•Sinoatrial block, type II •Sinoatrial block, type II

•Second-degree atrioventricular (AV) block,
type I
•Second-degree AV block, type II
•Nonconducted atrial premature impulse
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•Second-degree atrioventricular (AV) block,
type I
•Second-degree AV block, type II
•Nonconducted atrial premature impulse
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What do you think?

•Second-degree AV block, type II

P waves occur regularly in this tracing;
Some of them are conducted to the ventricles while others
are blocked; therefore, it is second-degree AV block.
In this tracing, when the P waves are conducted, the PR
intervals do not lengthen; therefore, this is second-degree AV
block, type II. 15 16

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 Recognizing
myocardial infarction (MI)
„ Series of predictable ECG changes occur in
MI
- pauses in the middle of a regular rhythm.
- there are no extra P waves during the pauses -- an „ ST-
ST-segment-
segment-elevation MI
indication that this is not AV block. (STEMI)--
(STEMI)--serious
serious type
- the pause is exactly twice the length of the shorter cycle, of MI, associated with
indicating regularly firing sinus impulses that fail to conduct more complications,
to the atrium at times; higher risk of death
This is SA block. Because the pause is
twice the shorter cycle, it is type II.
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Characteristic changes in AMI ST elevation

• ST segment elevation over area of
damage • Occurs in the early
R
• ST depression in leads opposite ST
stages
infarction P • Occurs in the leads
• Pathological Q waves Q
facing the infarction
• Reduced R waves • Slight ST elevation may
• Inverted T waves be normal in V1 or V2

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Deep Q wave T wave changes

• Only diagnostic change of

myocardial infarction R • Late change
R
ST
ST
• At least 0.04 seconds in P • Occurs as ST elevation
P duration is returning to normal
T
• Depth of more than 25%
T
• Apparent in many leads
Q Q
of ensuing R wave

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 Bundle branch block Sequence of changes in evolving
Anterior wall MI Left bundle branch block AMI
R
R R
ST ST
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 T
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
P P P

T
Q S Q
Q

1 minute after onset 1 hour or so after onset A few hours after onset

ST T
P P ST
P

T T
Q Q Q

A day or so after onset Later changes A few months after AMI

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Inferior wall STEMI

Inferior infarction
Inferior infarction
„ Elevated ST segments in
leads II, III, and aVF,
aVF, I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
which monitor the heart’s
inferior or bottom wall

„ Area of the heart perfused

by the right coronary artery

Right
27 coronary 28
artery

Septal MI Anterior-
Anterior-wall STEMI
„ Perfused by the left anterior „ Directly to the left of the septal area
descending (LAD) coronary artery
„ Also perfused by the LAD

„ ST-
ST-segment elevation seen in leads „ Most muscular, powerful
V1 and V2, the precordial or chest pumping wall of the heart,
leads located on the anterior chest responsible for large
wall over the septum proportion of cardiac output

„ ST elevation seen in V3 and V4

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 Anterior infarction Lateral-
Lateral-wall STEMI
Anterior infarction
„ Perfused by the circumflex artery
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
„ Muscular, contributes significantly to the
heart’s pumping ability

„ Monitored by precordial (chest) and

frontal (limb) leads

„ ST-
ST-segment elevation will appear in
leads I, aVL, V5, V6
Left
coronary 31 32
artery

Lateral infarction
Lateral infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Common dysrhythmias

Left
circumflex
coronary 33 34
artery

Sinus bradycardia Sinus bradycardia

„ Sinus rhythm slower than 60 beats per „ Signs and symptoms: hypotension,
minute
lethargy, fatigue, chest pain,
difficulty breathing
„ Commonly caused by ischemic heart
disease causing sinoatrial (SA) node to
malfunction

„ Also seen in MI, some medications (such

as beta-
beta-blockers), and well-
well-conditioned
athletes
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 Sinus tachycardia
„ Sinus rhythm faster than 100 beats per
minute

„ Related to physiologic cause: fever,

infection, pain, physical exertion, anxiety,
shock, hypoxia

„ May need beta-

beta-blocker if cause unknown

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Atrial fibrillation (AF)

„ Common dysrhythmia

„ Irregular heart rhythm with no meaningful

P waves

„ Atrial kick lost, atrias quiver due to depolarization

of atrial cells

„ Causes irregular ventricular rate, 40 to 180 beats

per minute

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Premature ventricular
contractions (PVCs)
„ Wide abnormal premature QRS
complex

„ Due to conduction through the

ventricle instead of His-
His-Purkinje
system

„ QRS greater than

0.12 second
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 Ventricular tachycardia (VT)
„ Rapid rate, 100 to 250 beats per minute

„ Wide, bizarre, QRS complex followed by

large T wave

„ Patient may be unconscious, pulseless,

pulseless,
apneic--
apneic--initiate
initiate CPR

„ If patient awake, treat as medical

emergency 43 44

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Hypercalcemia

Shortened QT interval (short/absent ST segment)

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Digitalis

Scooping of ST segment
Shortening of QT interval
Low amplitude of T wave
Elongation of PR interval
High amplitude of U wave
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 Digitalis poisoning Digitalis poisoning
„ Atrial tachycardia with AV block „ 1st degree AV Block

ƒ Mobitz I
ƒ AF with accelerated junctional rhythm

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Digitalis poisoning
„ Bidirectional VT

ƒ Ventricular bigeminy

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Tricyclic antidepressants (TAD) HYPOTHERMIA

Sinus tachycardia with a prolonged QRS interval

Rightward axis Sinus bradycardia with first-degree AV block is evident.
Tall R wave in lead aVR The downstroke of each QRS complex is slurred and is
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Markedly abnormal repolarization changes suggests TAD poisoning typical of a J (Osborne) wave (↓).

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