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David Didlake
Aug 31, 20221 min read

Lethal Blockade

Acute LAD occlusion in the setting of Right Bundle Branch Block and Left Anterior Fascicular Block.



Case Review:


Key features of Right Bundle Branch Block:

  • In general, there is no ST elevation throughout the 12 Lead ECG.

  • RBBB has expected slight ST depression, with T wave inversion, in V1-V3 when discordant to a positive R' wave.

  • A possible normal variant is lateral ST elevation (i.e., I/aVL/V5/V6) with bulky T waves when subsequent to a large, slurred S wave. This finding should be assumed new, until proven otherwise, during suspected Acute Coronary Syndrome.

  • Combination RBBB/LAFB has a high mortality rate in the setting of LAD occlusion.

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I am the Battalion Chief of EMS for Hilton Head Island Fire Rescue and obsessed with all things process improvement, system performance, human factors, crew resource management, and evidence-based performance measures for time-sensitive diagnoses.

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