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A 65 year old male presents to the ED after passing out at a local grocery store. He complains of recent dizzy spells and occasional shortness of breath. He has a history of hypertension and dyslipidemia. What does the EKG show and what is the diagnosis? Rate: 45 Rhythm: bradycardia, junctional escape rhythm Axis: normal PR: variable QRS: 0.10 ST: no ST elevations EKG diagnosis: complete heart block with junctional escape rhythm Clinical diagnosis: third degree heart block Treatment: atropine and pacemaker Practice Points: In third degree AV block, there is complete dissociation of the p wave and QRS complex due to lack of AV conduction. An escape pacemaker at a rate slower than the atrial rate paces the ventricles. When third degree AV block occurs at the AV node, a junctional escape pacemaker takes over with a ventricular rate of 40-60 beats/min, and because the rhythm originates above the bifurcation of the bundle of His, the QRS complexes are narrow. If the block is infranodal, then a ventricular escape rhythm takes over and the rate is usually slower than 40 bpm. If the block is somewhere else in the Purkinje system, wide QRS complexes occur. OMT questions: (Referenced from Foundations for Osteopathic Medicine 2nd edition p. 433) Bradyarrythmias and heart block are associated with somatic dysfunctions at which spinal cord level? OA and C2 (Vagal nerve) Tachyarrythmias are associated with somatic dysfunctions at which spinal cord level? T1-T2 (Sympathetic tone)
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