1/11. Wide QRS complex tachycardia: ECG differential diagnosis.Wide QRS complex tachycardias (WCT) present significant diagnostic and therapeutic challenges to the emergency physician. WCT may represent a supraventricular tachycardia with aberrant ventricular conduction; alternatively, such a rhythm presentation may be caused by ventricular tachycardia. Other clinical syndromes may also demonstrate WCT, such as tricyclic antidepressant toxicity and hyperkalemia. Patient age and history may assist in rhythm diagnosis, especially when coupled with electrocardiographic (ECG) evidence. Numerous ECG features have been suggested as potential clues to origin of the WCT, including ventricular rate, frontal axis, QRS complex width, and QRS morphology, as well as the presence of other characteristics such as atrioventricular dissociation and fusion/capture beats. Differentiation between ventricular tachycardia and supraventricular tachycardia with aberrant conduction frequently is difficult despite this clinical and electrocardiographic information, particularly in the early stages of evaluation with an unstable patient. When the rhythm diagnosis is in question, resuscitative therapy should be directed toward ventricular tachycardia.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/11. Treatment of advanced atrioventricular block with beta-adrenergic blockade therapy.A 26-year old woman, who experienced syncope associated with advanced AV block, was referred for further evaluation. Electrophysiological study showed normal SA and AV node physiology. syncope associated with advanced AV block on the electrocardiogram was induced by head-up tilt test. Oral propranolol therapy completely prevented the AV block and syncope induced by head-up tilt. The physician should be aware of advanced AV block associated with neurocardiogenic syncope, especially before permanent - pacemaker therapy is considered. The head-up tilt test is a useful diagnostic tool for an etiology of paroxysmal AV block.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/11. ED identification of cardiac septal abscess using conduction block on ECG.A case of cardiac septal abscess in a patient with a porcine bioprosthetic aortic valve who gradually developed a complete atrioventricular block on successive electrocardiograms (ECG) is reported. Emergency physicians should consider endocarditis with septal abscess in a patient with a prosthetic heart valve who presents with fever and a new conduction defect on ECG.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/11. Sudden death caused by benign tumor of the atrioventricular node.Histologic study of the conduction system of the heart of a 16-year-old girl who died suddenly demonstrated a benign mesothelioma of the AV node, with almost complete replacement of the structure by the tumor. Teh past history was unremarkable, except for few syncopal episodes at 9 and 11 years of age and during pregnancy. Immediately postpartum, she developed a 2:1 AV block and intermittent complete AV block. Six weeks later, during diagnostic work-up in the cardiac catheterization laboratory, she died suddenly. Electrophysiological studies during this work-up disclosed complete AV dissociation, with normal QRS complexes. The block was proximal to the His-bundle recording site, with a normal H-V interval. Occasional syncopal attacks in young adults should alert the physician to the possibility of this diagnosis and lead to pacemaker insertion.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/11. octreotide-induced bradycardia and heart block during surgical resection of a carcinoid tumor.octreotide may be a life-saving treatment in the case of an acute carcinoid crisis, but when given as an i.v. bolus in larger doses, it may cause significant effects on the cardiac conduction system. We describe cardiac conduction impairment observed during octreotide administration in a patient undergoing carcinoid tumor surgery. In this patient, i.v. boluses of 100 microg of octreotide resulted in symptomatic bradycardia, Mobitz type II atrioventricular block, and complete heart block. Perioperative physicians especially need to be aware of these potential effects because they may be more likely to occur during surgery because of the larger doses and boluses that are used to treat acute symptoms secondary to tumor manipulation. IMPLICATIONS: In some susceptible patients, i.v. bolus administration of octreotide may cause significant bradycardia and cardiac conduction defects. Therefore, when octreotide is administered as a bolus, it may be advisable to give it slowly while monitoring the electrocardiogram.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/11. Delayed perforation of right ventricle with cardiac tamponade: a complication of pacemaker implantation.We report a case of delayed cardiac tamponade that resulted from pacemaker implantation in the emergency room of a large urban hospital. A 19-year-old male patient with a pacemaker implanted 10 days earlier suffered from delayed perforation of the right ventricle with cardiac tamponade. A review of the literature revealed that cardiac tamponade is a rare complication of pacemaker implantation. Pacemakers should only be implanted by physicians with relevant experience, and emergency room physicians should be aware of the possibility of the associated complications and be prepared to treat them.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
7/11. Pacemaker spikes misleading the diagnosis of ventricular fibrillation.Pacemakers are used more and more in modern cardiology, because of the increasing age of patients and the increasing number of cases of congestive heart failure treated with biventricular stimulation. Twelve lead ECG traces of electro-stimulated patients normally can be interpreted correctly, but in emergency circumstances where only a three lead ECG trace is available (i.e. the usual monitoring setting in the pre-hospital arena or intensive care unit) recognition of the underlying baseline rhythm may be difficult. The case described illustrates how differentiation between true asystole and fine ventricular fibrillation in the presence of some confounding elements (e.g. pacemaker meditated spikes) can be challenging for the physician and life-threatening for the patient. Therefore, after selecting the best diagnostic ECG trace, direct current defibrillation should be used in the presence of a persistent but uncertain cardiac rhythm, even if it may be thought to be asystole or pulse-less electrical activity.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/11. Two unusual presentations of acute rheumatic fever.patients with acute rheumatic fever sometimes present with atypical signs and symptoms. In these circumstances, the Jones criterions may not be sufficient to make a clinical diagnosis. We describe here two patients with unusual presentations, highlighting that, both in regions where the disease is endemic, or where it is seen only sporadically, physicians should be more alert and careful in making the diagnosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/11. Complete atrioventricular block during cardiac catheterization: two cases reports in patients without pre-existing conduction abnormalities.Third-degree atrioventricular block has been well documented during ventricular catheterization of patients with underlying conduction abnormalities. Two cases reported here describe patients with normal conduction at baseline who sustained complete heart block during ventricular catheterization. Catheterizing physicians should be aware of this risk, which has not been previously reported.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/11. Phase abnormalities in right heart studies. Demonstration of six different patterns.Phase imaging abnormalities of the right side of the heart detected on multiple gated blood pool angiography (MUGA) have received less attention than similar abnormalities of the left ventricle. It has been found that certain different patterns of phase abnormalities of both right ventricle and right atrium are useful in the detection of six pathological conditions: right bundle branch block, ischemic right coronary artery disease, pericardial effusion, tricuspid regurgitation, pulmonary hypertension, and atrial septal defect. The authors emphasize the importance of these abnormal phase patterns during interpretation of gated cardiac studies, as they are helpful in directing the physicians attention towards the proper diagnosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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