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November 2004 EKG case Answers

 A 70 year old male with a history of insulin dependent diabetes is brought to the emergency department.  He is confused and is unable to give any history. He has a pulse of 36, blood pressure of 95/70, and glucose of 11.

What does the EKG show and what is the diagnosis?

Rate:    45

Rhythm:  Second degree type II heart block

Axis:    Left axis

PR:    Prolonged (> 0.20 seconds)

QRS:   Normal duration with RBBB pattern

T:   Inverted in V3, V4, AVL

       Flat in I, V6

EKG diagnosis: -Second degree Type II heart block

• -Incomplete RBBB (RBBB pattern with narrow < 0.12   seconds QRS complex)

Clinical diagnosis: -Second degree heart block Type II

   -Hypoglycemia

   -Hypotension secondary to bradyarrythmia

Practice Points: -This is second degree heart block Type II because each QRS complex which is conducted has a fixed PR interval

• -The symmetrical T wave inversion in V3, V4 is suggestive of ischemia.  The most typical T wave change of acute ischemia is deep symmetrical inversion.  Other forms of T wave change such as flattening, biphasic, and asymmetrical inversion are nonspecific.

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