Right Ventricle? ECGs....

[ERDoc]

Forget about the Right sided ECG, it's not warranted in this patient. the 12-lead shows a trifascicular block (RBBB, left anterior fascicular block, and 1st degree AV block). The problem is in her conduction system which has three blocks in it. This patient is in need of a pacemker.

Welcome to the City. You might want to review your heart anatomy and blocks before posting incorrect information.

[Dustdevil]

You might want to review your heart anatomy and blocks before posting incorrect information.

Go big or go home!

That's why I pace all bundle branch blocks with a rate under 80. If cardioversion doesn't work, that is.

[ERDoc]

Go big or go home!

That's why I pace all bundle branch blocks with a rate under 80. If cardioversion doesn't work, that is.

I realize that in the field you are limited on what you can do, but personally I like to use an open thoracotomy to manually repair anything worse than Wenkebach or an anterior fasicular block. I'm not normally one to criticize someone for stating something that is incorrect (that's how we learn), but I think it is the pompous way in which it was said, especially by someone making their first post. I think the OP had a great question that could be used for a teaching case and all of the responses were pretty good, but the tone turned with Echo. I'm going to let it go for now and let this thread go back to an educational one.

[hammerpcp]

I am not sure if this is what you were describing Fiznat but to do a modified 12 lead in order to get a good look at the right ventricle you move V4 to the same place but on the left side of the chest and you move V5 which becomes V8 to the back level with v6 at the midscapular line and V6 becoems V9 level with V6 as well on the left paravertebral line (on the spine). In our local protocols a modified 12 lead ECG is indicated if there is ST segment elevation in the inferior leads and/or ST segment depression in the septal leads. The modified twelve lead gives you a good picture of the distal RCA and the back of the heart.

not spell checked for my convenience.

[AZCEP]

At worst you may have wasted some electrodes by placing more of them when you didn't really need to.

At best you would have found something that was not showing up in the leads you had. I don't see any reason to look at the right side leads, but to say you were wrong in looking isn't real professional either. You looked for more information and didn't find it. You wouldn't have known that if you hadn't looked in the first place.

[captainstandup]

Perhaps part of the answer you seek, young Jedi, rests in this question. From a purely hemodynamic perspective, why could it be important to have an early indication of right ventricular involvement?

[rnmedic]

First of all, Fiznat, you did good in doing the Right sided 12. It was warranted based on history. Someone asked a questiona bout flipping V1-V2, you do need to reverse them to get a true image of the right side (in as much as you get with that set-up). As for the Dr. reaction, don't let it get ya down. Each Doc puts a different level of importance on EKG ranging from worthless to definitive. And I am afraid that R sided EKGs are viewed farther toward the worthless side by most. I still think they are worthwhile in the field. Early detection and documentation of changes can be critical to pt care. While the findings of RVI could prevent you from a precipitous BP drop during treatment or at very least give you aheads up to prep the pacing pads. Keep being thorough and don't let anyone tell you otherwise. You will save more lives and be a better medic for it.

[ERDoc]

First of all, Fiznat, you did good in doing the Right sided 12. It was warranted based on history. Someone asked a questiona bout flipping V1-V2, you do need to reverse them to get a true image of the right side (in as much as you get with that set-up). As for the Dr. reaction, don't let it get ya down. Each Doc puts a different level of importance on EKG ranging from worthless to definitive. And I am afraid that R sided EKGs are viewed farther toward the worthless side by most. I still think they are worthwhile in the field. Early detection and documentation of changes can be critical to pt care. While the findings of RVI could prevent you from a precipitous BP drop during treatment or at very least give you aheads up to prep the pacing pads. Keep being thorough and don't let anyone tell you otherwise. You will save more lives and be a better medic for it.

I have to respectfully disagree with you rnmedic. Flipping V1 and V2 will not give you anything different. You will be looking at the same views with different eyes. If you want to look for a right sided MI you need to take the same eyes and change the view. All you really need is to look at V4R. It has been shown to be 93% sensitive and 95% specific (Roth A, Miller HI, Kaluski E: Early thrombolytic therapy does not enhance the recovery of the right ventricle in patients with acute inferior myocardial infarction and predominant right ventricular involvement. Cardiology 1990; 77(1): 40-9).

[captainstandup]

Interventional cath lab is likely their only hope of salvaging muscle and this would require early action by the patient, good diagnostics by paramedics with transport to the nearest APPROPRIATE facility.

[emstrainer]

Fiznat,

First off I applaud you for going the extra mile for your patient. Most medics would stop with the initial 12 Leads and scratch their heads. Any chance you have to look at additional heart muscle is good in the context of understanding what may or may not be happening. The initial ECG does show inverted T Waves, which is a sign of ischemia. Now this may very well be caused by the bradycardia. I would lean this way due to the additional T Wave Inversion in the Anterior Leads ..... This is not from an old event, T Waves are not typically inverted. It may be fixed with simple oxygen administration. Maybe not ....

As far as the Right Sided debate, I would like to offer my thoughts. First off, the Right Ventricle is viewed in the original 12 Lead ECG with V1-V2. In this ECG we have RBBB, so we cannot get a good look at the RV .... Also - V4r is a much better view of the RV, and this is the Lead of Choice for Diagnostic purposes. It is totally appropriate to look at the RV to Rule Out RVI. Typically I teach Medics to look at the RV in the setting of Inferior AMI, but there is a small population whose Inferior Wall is fed by the LCX. In this case a person with a proximal occlusion of the RCA would have RVI with no signs on the initial 12 Lead. These are the ones that you are looking for in this case. It may truly be Life Saving...because as you found out - Most ED Docs aren't interested in looking for this. It just ain't high on the priority list. If we don't find it Pre-Hospital, time will be lost. My crews have found 2 Posterior AMI's in the field which led to Rapid Triage to a Cath Lab .... On a personal note I have a good friend who went to the same ED with a Posterior AMI and sat in the ED for 4 hours until his enzymes bumped. Muscle was lost ....

One last note - The RBBB is typically fed from the LAD, but it may receive its blood supply from the PDA. In the setting of Proximal RCA Occlusion you could have this Tri-Fasicular Block presentation. I think it was a good thought to take a look ....

Keep up the good work, and keep asking WHY ... I still learn something new every day ....

Jason Kinley

Xania,Ohio