An unusual case of right bundle branch block

Here's a case submitted by Captain Jack Sparrow from the UK Ambulance Forum.

I'm presenting it here with minor modifications.

Turns out Mark Glencorse isn't the only clever Brit! We Yankees can learn a lot from the way they do things across the pond.

EMS is called to the residence of a 69 year old male with a chief complaint of chest pain.

  • Onset: Gradual while driving
  • Provoke: Nothing makes the pain better or worse
  • Quality: Describes pain as pressure
  • Radiate: The pain does not radiate
  • Severity: 3/10
  • Time: Similar episode over the weekend while gardening

Past medical history: CVA x 13 years ago, AF
Past surgical history: None
Allergies: No know drug or environmental allergies
Medications: Warfarin, digoxin, others

On arrival the patient is found sitting in a chair.

Skin is pink, warm, and moist.

He appears ill.

Vital signs

  • RR: 16 regular
  • Pulse: 130 irregular
  • NIBP: 137/102
  • GCS: 15
  • BGL (BM): 146 (8.1)
  • SpO2: 99 on RA

Breath sounds: clear bilaterally with normal air entry

No obvious trauma or anything else out of the norm.

The cardiac monitor is attached.

A 12-lead ECG is captured.

What's wrong with this patient?

See also:

An unusual case of right bundle branch block – Discussion

21 Comments

  • Bill C says:

    Appears to me that it is atrial fibrillation, rapid ventricular response, with WPW. There are prominent delta waves (very prominent in the precordials) with the Q-waves and flattened T-waves in the inferior leads that can accompany WPW.

    Treatment would include:
    1. ASA depending on medical director’s preference given coumadin Rx.
    2. Consider procainamide or amiodarone to control the rate.
    3. Pain management with fentanyl 0.5-1 mcg/kg.
    4. Cardioversion for any signs of decompensation
    5. Transport to a hospital with PCI and an EP lab for ablation.

  • Tom B says:

    Bill –

    Are you saying this isn’t a RBBB but rather WPW Type A? Does your Medical Director not feel comfortable with giving aspirin to chest pain patients who already take warfarin? That’s the first time I’ve heard that.

    Tom

  • Bill C says:

    Yes, my impression is WPW Type A (upright V1 & V2 vs. B that has a negative V1 & V2 if I remember correctly). I’ll defer to you, but I’ve heard of a Type C and have no idea what that one is.

    Our medical director advocates ASA for all CP and most ACS/arrhythmia unless there is a true anaphylactic reaction. We work in a mother-may-I system and if we forget to administer it prior to call in we have some old school physicians that believe ASA is not necessary if the patient is on coumadin…One of our adjacent systems does not give ASA if coumadin is prescribed. Wacky but true, anecdotal practices.

  • Ben says:

    Presuming ASA is Aspirin and Coumadin is warfrin(?); just to add that giving any pt Aspirin who is currently on warfrin is contra-indicated in the UK ambulance service. I believe that is to do with CVA risk.

  • arguably meets criteria for LAFB. the delta-like wave is probably just the delayed intrinsicoid deflection that comes with LAFB.

  • steve says:

    Giving aspirin to someone on warfrin is no longer a contra indication in the UK, as it works on different clotting cascades to warfrin.

  • kilohotel says:

    Aspirin is contraindicated in the UK if the patient is on warfarin. Aspirin and warfarin are transported on the same protein in the blood plasma, but aspirin binds preferentially. So aspirin administration increases the amount of free (hence active) warfarin in the bloodstream, which is not usually desirable.

    Whether this is a problem (or indeed helpful in the context of MI) is no doubt debatable!

  • Christopher says:

    AF w/ RVR, RBBB. Inferior STD, STE in aVR, V4 doesn’t look right but its a transition lead. If this were WPW Type A you would not have the Q wave (or at least that is my understanding). I’d like to control the rhythm on this one…I’ll get back to this post (receiving call).

  • Mike C. says:

    Afib with a RBBB, rate is a little high which could be contributing to the chest discomfort but I’m also seeing significant depression in II and AVF.

    ASA, IV, NTG, O2 if he starts getting dyspneic. We’ve got no issue giving ASA to warfarin users. Serial 12leads, keep an eye on vitals and run ’em on in.

  • Nickinbrisbane says:

    Hmm so im guessing he is on those meds for AF. My needle in the hay stack is digitalis toxicity resulting in rate induced chest pain. Due to shortened QT, inverted Ts and possibly rate.

    Would have to see the pt to rule in or out ischaemic chest pain.

    Out protocols in my state in Australia is Aspirin as a precaution with PTs on warfarin- if they have thorough understandings and knowledge of current INR you can justify not administering it…. But clinicians should remember the efficacy in AMI. So it’s upto us and 99/100 we give it…. If it’s say straight forward rapid AF you could justify not giving it if for example they have problems maintaining therapeutic INR.

    Anyway my 2 cents and plenty of discussion for this case- thx

  • Tom B says:

    Nickinbrisbane –

    Did you mean to say shortened QT? QTc is 479 ms.

    Tom

  • Dave B says:

    looks like AF with RVR, and RBBB + LAFB… I agree with Christopher about STD in inferior leads and STE in aVR… also, i believe the Q wave in V1 is abnormal, as is the ST elevation in see in V1-V4.. unlike LBBB, RBBB should not distort the ST segment, so i believe this ECG is very suspicious for STEMI.

  • Quick and Dry says:

    Concordant STE Septal and Anterior leads, with subtle but present inferior reciprocal depression. This combined with what looks like STE in aVR makes me think proximal LAD, or left main occlusion. STEMI in the presence of tachycardia looks odd, but those rules don’t apply to Afib. I agree with the bifasicular block, and wonder if the LAFB aspect isn’t new onset secondary to anterior ischemia. Treat per chest pain protocol and activate the cath lab.

  • Nickinbrisbane says:

    Tom, yeah sorry shortened.

    On a glance of ECG today does anyone else see elevation in avR?? If so LCA occlusion… Our service is trying to get this sign approved for cath lab activation

  • Tom B says:

    Nickinbrisbane –

    I actually think that’s a terminal R-wave in lead aVR!

    Tom

  • Christopher says:

    It certainly is an interesting RBBB with the narrower limb leads and wider precordials. Could the narrowing be secondary to the ST changes due to the AMI?

  • John Smith says:

    Aspirin is most denately contracindicated in the uk for warferin patient s with chest pain, but given as a stat dose of 300mg in all patients with cardiac chest pain except those allergic or under 16

  • John Smith says:

    just a point of reference –  the UK ambulance services do have medical directors and all paramedics are autonomous practitioners who follow  a set of guidelines but agreed by the Joint Royal colleges for ambulance services (JRCALC). We dont have med control and have to ask before we commence treatment or give drugs etc
     

  • John Smith says:

    first comment should have said definatly not cotraindicated, sorry, not concentrating

  • CMY says:

    V-4 STE anterior STEMI (isolated) with inferior reciprocols.  PCI hospital with appropriate STEMI care.

  • Soozey G. says:

    I'm seeing some STE in the anterior leads. Also seeing possible Delta waves throughout. Anyone else agree with STE?

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