Bifascicular Block and Second Degree AV Block
1. In asymptomatic individuals, chronic bifascicular block does not usually require cardiac work-up; the prognosis is generally benign
2. The following high-risk features, however, warrant urgent evaluation:
a. Bifascicular block and syncope
b. Bifascicular block and intermittent second degree AV block
c. 1:1 AV conduction at slower sinus rates but higher grade block (i.e., 2:1 AV conduction) at faster
sinus rates (“acceleration-dependent AV block”)
3. Evaluation and management of patients with bifascicular block:
a. Actively search for nonconducted P waves in the 12-lead ECG
b. Always review telemetry strips and actively search for episodes of second degree AV block
(blocked P waves)
c. In symptomatic patients with bifascicular block who develop acceleration-dependent second
degree AV block and a very slow ventricular rate, carotid massage or IV beta blocker can
paradoxically restore 1:1 AV conduction
d. Patients with bifascicular block and syncope require admission and cardiology consultation for
possible pacemaker implantation
e. Patients with bifascicular block and intermittent second degree AV block require cardiology
consultation for possible pacemaker implantation
The Pacemaker ECG
1. Ventricular pacing: always try to determine what the atria are doing
2. Sinus P wave in front of each paced QRS complex indicates dual chamber (A-V sequential) pacemaker where the ventricular pacer is tracking sinus rhythm
3. Two pacer spikes about 5 mm apart indicate AV sequential pacing
4. If there are no P waves or 2 pacer spikes, search for the presence of retrograde P waves after the paced QRS complexes; retrograde P waves are sharp negative in the inferior leads (in II, III and aVF) and usually upright in V1
5. If there are no P waves in front of the paced QRS complexes and no retrograde P waves present, always consider the possibility of underlying atrial fibrillation
I. STEMI ECG Pattern in the ICU
1. In the ICU setting, 5% of all ECGs show a STEMI pattern
2. At least 85% of these patients are found not to have STEMI
3. Frequent causes of STEMI ECG in the ICU:
a. Pericardial irritation by chest tube, mediastinal mass, pneumothorax,
b. Abdominal pathology, acute abdomen, pancreatitis
c. Hyperkalemia, acute renal failure, MSOF, shock
d. Stress-induced cardiomyopathy, septic myocarditis
4. Evaluation and management:
a. Try to find the underlying cause
b. Stat bedside echocardiogram
c. Urgent cardiac catheterization is reasonable in selected cases
II. The Pacemaker ECG
1. If the paced QRS is upgoing in lead I: RV apical pacing
Indication: bradycardia (A-V block or atrial fibrillation with slow ventricular response)
2. If the paced QRS is downgoing in lead I: biventricular pacing
Indication: severe systolic heart failure (EF < 35%) and left bundle branch block
1. History and physical exam are key elements of discerning benign chest pain from cardiopulmonary pathology.
2. Obtain an EKG in all children presenting with chest pain or syncope.
3. EKG is the most sensitive diagnostic test for pericarditis.
4. Many cases of myocarditis will present with primarily respiratory complaints.
5. Ask about family history of deafness and unexplained sudden death.
6. Check for hepatomegaly in infants with vague or respiratory complaints.
Abnormal Presentations of ACS
-Always think of this on your differential
-Frequently re-evaluate patients
-Interpret ECGs in a systematic fashion - and do this every time!
RBBB and STEMI
- No criteria for STEMI as there are in LBBB
- Any ST elevation is abnormal
- Read your EKG’s carefully and compare to old
- It is never a bad idea to get serial EKG’s if the presentation is unclear ("One ECG Begets Another")
De Winter’s Sign
- This is an Anterior STEMI Equivalent!
- Seen in 2% of acute LAD occlusions
-Tall prominent symmetric T waves in the precordial leads
-Upsloping ST segment depression > 1mm at the J point
-No ST elevation in the precordial leads
-ST elevation in aVR
-Widespread horizontal ST depression, most prominent in I, II, V4-V6
-ST elevation in aVR >1mm
-ST elevation in aVR >V1
- Defined as blood in the anterior chamber
- Complete a full visual examination
- Must evaluate for ruptured globe
- Ruptured Globe = Tetanus, antibiotics and emergency consultation
- Evaluates for aqueous humor leak secondary to violation of the anterior chamber
- Apply topical anesthesia
- Paint eye with fluorescein dye
- Test is positive if there is a stream of dye emanating from the wound site
Sneaky Ectopic - Dr. Nichols
GIB and Aortic Graft - Dr. Beverly
Pulmonary embolism + pleural effusion - Dr. West
Traumatic Ptx, Be Kind - Dr. Robertson
Intoxicated with Chest Pain
Infected Kidney Stone
Post-op Incisional Hernia
- Seen in over 10% of patients; up to 25% of patients with incision infection.
- More common in midline incision, more common in upper abdomen vs lower abdomen.
- Dr. Gibbs Pearl: If a patient presents to the ED with 30 days of their surgery (and is not there for an obviously unrelated complaint) contact the Surgeon to discuss the patient's presentation.
- Surgery Pearl: evaluation for post-operative pain from lap chole can involve RUQ ultrasound to look for signs of abscess. Also consider biliary studies if concerned for biliary leak, biloma development.
Negative CT Calcium score in ACS
- Negative CT calcium score misses ACS very rarely.
- Quick test that is non-invasive, has no contrast, does not require patient participation, does not rely on patient heart rate or ability to exercise.
- If used in correct patient population, NPV is between 93-97% with a sensitivity of 99-100%.
- Dr. Garvey Pearl: Recognize that your clinical gestalt trumps any protocol or clinical decision rule and do what you think is best for the patient.
- Idiopathic is most common
- Also: trauma, malignancy, infection, uremia, collagen vascular disease, hypothyroidism, etc
- Dependent on rate of pericardial fluid accumulation
- Symptoms: Sinus tach -> cardiogenic shock, distended neck veins, respiratory distress, Beck's triad
- Work-up: EKG, chest x-ray, ultrasound (most important!)
- Tamponade is a clinical diagnosis NOT an echocardiographic diagnosis, but US is a crucial adjunct
- Definitive treatment = fluid removal (pericardiocentesis vs surgery)
- Fluid resuscitation to increase preload
- Avoid PPV and nitrates at all cost
Indication for ED thoracotomy
- Penetrating thoracic trauma, with witnessed signs of life (on arrival or en route), and less than 15 min of arrest w/ CPR
1) Keep tamponade on your differential
2) Employ ultrasound early
3) Treatment = pericardial pressure relief
4) Fluid resuscitation can be life saving (increase preload)