Right bundle branch block, bifascicular block

[Just Plain Ruff]

No Scenario here. I just need to get some info.

74 y/o male, sudden onset weakness. He thought it was diabetic reaction, sugar 100

EKG shows Atrial Fib (he knows he has this)

Also showed Right bundle branch block(easy to see on ekg)

Also showed Bifascicular block (don't know really what to look for on the EKG)

What is the significance of a Bi-fascicular block in the presence of a right bundle branch block

Did this patient warrant air transport - we were on scene at his house, 85 miles away from nearest cardiac center

20 miles from nearest acute care hospital

Just need some references or info on RBBB and bi-fascicular blocks.

[chbare]

Remember your A&P for this one. You have three primary fascicles. One on the right and two on the left. The two left fascicles are the left anterior and left posterior. So, with a RBBB, you have a block of the right fascicle, but the two left fascicles are intact. A RBBB with a bifascicular block means you have a RBBB and one of the two fascicles on the left are compromised. Clearly, this may be a problem as you only have one pathway for conduction to travel. A trifascicular block would be a block of all three fascicles and a patient who may look at getting a pacemaker. You could also consider a LBBB bifascicular as you have both the left anterior and left posterior fascicle blocked.

I cannot comment on your patient. I would not go so far as to say a bifascicular block alone requires q helicopter. This guy may have been living with a bifascicular block for years. It is something to monitor however. Clearly, these blocks are a concern when you actually see them occur while doing serial ECG's on a patient having an MI.

You should familiarise yourself with identifying these anomalies as the machine can lie on occasion. This requires being able to identify axis deviation and bundle branch blocks. If yup are able to do this, I have an easy algorithm for putting it all together. Likewise, I use the ResQShop software on my iPhone that actually guides you throughout the process step by step.

Take care,

chbare.

[chbare]

Apologies for the typos, meaty fingers and an iPhone do not always mix.

Take care,

chbare.

[chbare]

This wonderful work of art should help:

Take care,

chbare.

[spenac]

Bifascicular block is going to show up as a combination of two blocks on the twelve lead. Leads I,II,III will help you determine if you have a hemiblock. In your case combining the hemiblock with the RBBB gives you a Bifascicular block. Bifascicular blocks are a contraindication of Lidocaine so it is important to be able to determine them.

Bob Page referenced below teaches a simple method to find hemiblocks.

Based on his seminar and book:

http://www.multileadmedics.com/documents/MLM2005Master.pdf

Page 21

"A Bifascicular block represents a serious

conduction problem for the heart. In a

bifascicular block, 2 out of 3 pathways to

contract the ventricles in an organized fashion

have been blocked. This can compromise

myocardial contractility."

"Preparing For the Symptomatic Patient with A Bifascicular Block:

♥ The patient is much sicker than an uncomplicated MI.

♥ They may go into complete heart block suddenly and without warning.

♥ They may drop their blood pressure precipitously, especially if the QRS is > 170ms. If

so remember the three things to do before you give nitro and ask how much they weigh!

♥ They may just go into V-Fib or VT without warning.

♥ Anti-arrhythmia drugs are contraindicated in cases of PVCs or transient

tachyarrhythmia. Treat the cause of the arrhythmia!

♥ In patients with S/S of an MI and all unstable patients, place Quick Combo or multifunction

pads on the patient.

♥ Be prepared to PACE the patient.

♥ Be prepared to DEFIBRILLATE the patient

♥ Some patients may tolerate this condition well, until they get up to go do something. The

heart cannot fill the request for extra output due to compromised conduction system."

Edited May 23, 2010 by spenac

[Just Plain Ruff]

No Scenario here. I just need to get some info.

74 y/o male, sudden onset weakness. He thought it was diabetic reaction, sugar 100

EKG shows Atrial Fib (he knows he has this)

Also showed Right bundle branch block(easy to see on ekg)

Also showed Bifascicular block (don't know really what to look for on the EKG)

What is the significance of a Bi-fascicular block in the presence of a right bundle branch block

Did this patient warrant air transport - we were on scene at his house, 85 miles away from nearest cardiac center

20 miles from nearest acute care hospital

Just need some references or info on RBBB and bi-fascicular blocks.

I have not been able to upload this to the site cause it's too big so I put it on photobucket. I was able to scan the 12 lead in question

Ruff

http://i4.photobucket.com/albums/y136/ruffems/12lead.jpg

[spenac]

Lead I upright, Leads II,III downward indicates pathological left axis indicative of an anterior hemiblock. Wide QRS upright in V1 confirms RBBB. Irregularly irregular with no p waves consistent with afib. Looks like a PVC in AVR, AVL, AVF.

This patient would not be treated with lido for his PVC's as he has at least two blocks which equal bifascicular block.

[chbare]

It's likely he's had this for a while. What did you end up doing?

Take care,

chbare.

[Just Plain Ruff]

It's likely he's had this for a while. What did you end up doing?

Take care,

chbare.

My gut was not to take him to our local hospital. My gut was correct.

He arrived at the cardiac center, worked up for Right sided AMI. Don't know what his outcome past that was. I do know that his troponin was around 5.4 or so.

I called the ICU he was at the day before and they said that there was no evidence of any bi-fascicular block on his EKG but he did have the A-fib and the right bundle block.

I did indeed fly him to the cardiac center. More than likely he would have tolerated the trip by ground though.

The sudden onset of profound weakness without the presence of low or high blood sugar really pushed me towards my decision.

I think he may be getting a defib/pacemaker placed in a day or so. The nurse wasn't sure.

[spenac]

My gut was not to take him to our local hospital. My gut was correct.

He arrived at the cardiac center, worked up for Right sided AMI. Don't know what his outcome past that was. I do know that his troponin was around 5.4 or so.

I called the ICU he was at the day before and they said that there was no evidence of any bi-fascicular block on his EKG but he did have the A-fib and the right bundle block.

I did indeed fly him to the cardiac center. More than likely he would have tolerated the trip by ground though.

The sudden onset of profound weakness without the presence of low or high blood sugar really pushed me towards my decision.

I think he may be getting a defib/pacemaker placed in a day or so. The nurse wasn't sure.

I know you posted your 12 lead that does show bi-fascicular block, but did you happen to do a 15 lead. If not sure how here is from Bob Page link posted earlier:

"15 Lead ECG

V4R - 5th IC space, mid clavicular line right side

V8 - 5th IC space mid scapular V9 - 5th IC space between V8 and spine

Run 12 Lead as usual but on the second 12 lead, Use leads V4 for V4R, V5 for

V8, and V6 for V9."

Make sure you label V4 as V4R, V5 as V8, V6 as V9.

With that you may have caught the right sided MI. Standard 12 lead shows only about 50% of acute MI's. Adding those 3 leads helps you capture another about 25%. So with about an additional $0.21 and another 30 seconds time you now can capture about 75% of MI's.