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ECG Abnormalities_Part 10

Sunday, October 24, 2010

A 86 year old male with no significant past medical history to clinic with a complaint of generlized weakness, dizziness, and dyspnea on exertion. Mild lower extremity edema, paroxysmal nocturnal dyspnea, and orthopnea are present. No chest pain has occured. He is not taking any medications.

His temperature is 37.0, blood pressure 80/40mmHg, heart rate 40/BPM, respiratory rate is 16/min. Mild jugular venous distension is present, he is bradycardic and regular without any murmurs. His lungs are clear to auscultation. The rest of his exam is normal.

His ECG is below:

Identify the Abnormality in this ECG strip?


The ECG findings include:Junctional rhythm

A junctional rhythm occurs when the SA node is not able to generate an action potential and AV node acts as the main pacemaker of the heart. In this instance, the P wave morphology (normally generated when the SA node fires causing atrial depolarizaion) will be altered since its origin is no longer at the SA node and is instead at the AV node. The direction of conduction to the atria in a junctional rhythm is considered "retrograde" since it is traveling up the atria from the AV node instead of down the atria from the SA node. This results in an inverted P wave in lead II (normally upright in sinus rhythm) and an upright P wave in aVR (normally inverted in sinus rhythm).
Depending on the exact location of the pacemaker in a junctional rhythm, the P wave location may vary. If it occurs slightly above the AV node (low atrium), then the P wave will actually occur slightly before the QRS complex is seen. This will result in the P wave appearing just before the QRS, but PR interval will be short (< 0.12 ms). If the pacemaker occurs at the junction, the P wave and QRS complex may be exactly overlying and you may not be able to identify any P waves at all. If the pacemaker occurs lower in the junction, the QRS complex may actually occur before the P wave (the P wave will be seen after the QRS complex). In this case a retrograde P wave can be identified just before the QRS complex with a short PR interval, thus the pacemaker is located high in the AV node or perhaps in the low atrium. Causes of a junction rhythm include chronic degeneration of the SA node (termed "sick sinus syndrome"), hypoxia, myocardial ischemia, hyperkalemia, digoxin toxicity, elevated vagal tone, and medications known to supress the SA node (beta-blockers and non-dihydropyradine calcium channel blockers).


22 Responses to ECG Abnormalities_Part 10

  1. Anonymous Says:
  2. Congestive heart failure?

  3. drbaluch Says:
  4. junctional rythm as no p waves secondary to medications he is taking

  5. Anonymous Says:
  6. bradycardia, with multi focal unconducted P waves in lead I and Bifid P waves in leads II and V1 (P mitrale) suggestive of left Atrial dilatation secondary to left sided heart failure and presence of orthopnea & PND are suggestive of Pulmonary venous congestion as sequelae of left atrial dilatation and mild pedal edema and JVP elevation are sugestive of ongoing Right heart failure which may be secondary to Left heart failure so overall picture is likely of

  7. Anonymous Says:
  8. Ecg shows herat rate 40pm. Left axis deviation no rythm abnormality Normal p waves QRS complex is also normal And no changes in ST segment. The given data is highly suggestive of CONGESTIVE CARDIAC FAILURE

  9. Anonymous Says:
  10. junctional bradycardia with Q,s in lead iii,

  11. Anonymous Says:
  12. Left axies devition.bradycardia.impending block,

  13. man Says:

  15. Anonymous Says:
  16. rytme sinusale regulier bradycardisant avec onde P bifide et lefte axe deviation QT long

  17. Anonymous Says:
  18. As because of the congestive heart failure heart rate is slow, otherwise no any significant changes in ECG, but just mild left axis deviation.

  19. Anonymous Says:
  20. This is all about symptomatic bradycardia with low atrial rhythm (attention to negative p waves in inferior leads II,III,AVF) possibly caused by drugs overdosage suck as Beta blockers, Ca channel blockers
    Emergency temporary pacemaker insertion should be done

  21. Anonymous Says:
  22. Dx: CHF.
    Rhythem: inverted p waves,= junctional rhythem, bradycardia would warrant pacemaker. My humble guess.

  23. Anonymous Says:
  24. Short PR interval, delta waves in I, II, V4...CONSISTENT WITH PRE-EXCITATION (WPW Syndrome)

  25. Archana Says:
  26. junctional rhythm giving brady with hemodyanamic instability

  27. Anonymous Says:
  28. junctional rhythm

  29. Anonymous Says:
  30. Junctional Rhythm, Cardiogenic Shock BP 80/40.

  31. Anonymous Says:
  32. First off, I would like to address the fact that I noticed a few people say that the patient has a left axis deviation. How did you come up with this. The patients axis is normal. Everyone aggrees that a normal axis will have upright QRS complexes in I, II, III, and aVF. You need more the one negative QRS compolex in the frontal leads to call left axis deviation. This patient has a (very small) negative complex in lead III only. The cardiac vector less then 30 degrees will do this. The QRS complex in lead aVF is overall positive so the cardiac vector (axis) must be more then 0 degrees. I would approximate the cardiac vector as being @ 20 degrees.......which is normal.

    What I see in this 12 lead is a short PRI with PW inversion in the inferior leads being the most noticable......High Junctional Rhythm. Being that the pt does not take medications (so he says), I would verify this information to R/O medication OD on CCB or Beta Blockers like someone said (good idea). The problem and symptoms this patient is haveing is due to a slow heart rate, so treatment should be aimed at increasing the rate. The pt says that he has PND and orthopnia, but auscultation of the lungs say that they are clear. There is other evidence of CHF with the mild pedal edema, a sign of right-sided CHF. If this right sided CFH is secondary to probable left-sided CHF; Why is his pulmonary edema so mild as to not be heard with auscultation?.......hummm.

    I would say that all this is secondary to porr cardiac function from the low rate (junctional rhythm). This patient has a tire 86 year old heart where something caused the patient's SA node to slow below the junctional rate, or stop completely.

    Again, treatment should be aimed at the bradycardia. Atropine Sulfate @ 0.5mg may help. If not, TCP or temp. internal pacemaker can be established until a permanent pacemaker can be implanted.

    Just my opinion though.

  33. Anonymous Says:
  34. junctnl rhythm (brady cardia)

  35. Anonymous Says:
  36. junctional rhythm

  37. Anonymous Says:
  38. idont know

  39. Anonymous Says:
  40. junctional rhythm

  41. Anonymous Says:
  42. isn't that VTACH???

  43. Junctional rhythm with HR about 40bpm, and non-significant Q waves in lead III.


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