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Orthopedics

  October 2004 EKG case:

A 90 year old retired steel worker collapses at home in Pittsburgh.  He is brought to the Emergency Department in a slightly confused state and other than a bradycardia; there are no abnormal clinical findings.  He had no chest pain and he is on no medications.

What does the EKG show and what is the diagnosis?

Rate:    45
Rhythm:  Sinus bradycardia
Axis:    Normal
P:   Normal
PR:    Prolonged (0.40 sec)
QRS:   Normal
ST:    Normal
T:   Normal

EKG diagnosis: 1) Sinus bradycardia

     2) First degree heart block on EKG (regular PR interval)

     3) Second degree Type 1 on rhythm strip

Clinical diagnosis: Slow sinoatrial node with disease of the conduction pathways

• Practice Points: -First degree heart block is diagnosed when the PR interval (measured from the beginning of the P-wave to the beginning of the QRS complex) exceeds 0.20 seconds
• -It may be due to drugs (digoxin, beta-blockers, verapamil, and diltiazem), degeneration of the AV conducting system, myocarditis, or acute myocardial infarction.
• -Degenerative disease of the AV conducting pathways initially gives rise to intermittent and variable block ranging from prolongation of the PR interval through to complete heart block.
• -In this patient, the first degree heart block was the clue to intermittent complete heart block (later documented in the ICU) caused by presumed degeneration of the conducting system.

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