ECG OF THE WEEK M7 UNIT  Prof. Dr. P. Vijayaraghavan’s unit By Dr. J. Stalin Roy
Background <ul><li>17 yr old female presented with history of consumption of detergent bleach ‘ala’ (around 50ml) </li></u...
<ul><li>Normal sinus rhythm </li></ul><ul><li>Rate 85,  </li></ul><ul><li>Normal P wave,  </li></ul><ul><li>PR interval </...
<ul><li>PR interval has normalized to </li></ul>140 ms (0.14 sec)  ECG taken on the 3 rd  day
<ul><li>This is a rare case presenting with  first degree AV block  after consuming ‘ALA’ bleach, the main component of wh...
Sodium hypochlorite poisoning <ul><li>Ingestion of small volumes of sodium hypochlorite causes burns to the mouth and thro...
First-degree AV block <ul><li>First-degree atrioventricular (AV) block is defined as a PR interval exceeding 0.20 seconds....
Causes  <ul><li>Athletic training </li></ul><ul><li>Acute MI </li></ul><ul><li>Idiopathic degenerative diseases of the con...
<ul><li>Mitral or aortic valve annulus calcification  </li></ul><ul><li>Infectious disease:  </li></ul><ul><ul><li>Infecti...
<ul><li>Collagen vascular disease:  </li></ul><ul><ul><li>Rheumatoid arthritis </li></ul></ul><ul><ul><li>systemic lupus e...
<ul><li>Signs   </li></ul><ul><ul><li>Asymptomatic at rest.  </li></ul></ul><ul><ul><li>Markedly prolonged PR interval may...
Workup  <ul><li>Imaging: </li></ul><ul><ul><li>In patients with first-degree AV block and left ventricular systolic dysfun...
Treatment  <ul><li>Patients with asymptomatic first-degree AV block need no treatment </li></ul><ul><li>In patients with s...
<ul><li>Complications </li></ul><ul><ul><li>Progression to higher degrees of AV block </li></ul></ul><ul><ul><li>Reduction...
Pseudo pacemaker syndrome <ul><li>AV  dyssynchrony syndrome  </li></ul><ul><li>Found in </li></ul><ul><ul><li>Extremely pr...
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ECG: Toxin induced First degree Heart Block

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  • Idiopathic degenerative diseases of the conduction system Lev disease: This is due to progressive degenerative fibrosis and calcification of the neighboring cardiac structures, &amp;quot;sclerosis of the left side of cardiac skeleton,&amp;quot; including mitral annulus, central fibrous body, membranous septum, base of the aorta, and crest of the ventricular septum. Lev disease has an onset about the fourth decade and is believed to be secondary to wear and tear on these structures caused by the pull of the left ventricular musculature. It affects the proximal bundle branches and is manifested by bradycardia and varying degrees of AV block. Lenègre disease: This is an idiopathic, fibrotic degenerative disease restricted to the His-Purkinje system. It is caused by fibrocalcareous changes in mitral annulus, membranous septum, aortic valve, and crest of the ventricular septum. These degenerative and sclerotic changes are not attributed to inflammatory or ischemic involvement of adjacent myocardium. Lenègre disease involves the middle and distal portions of both bundle branches and affects a younger population than Lev disease. Idiopathic degenerative diseases of the conduction system Lev disease: This is due to progressive degenerative fibrosis and calcification of the neighboring cardiac structures, &amp;quot;sclerosis of the left side of cardiac skeleton,&amp;quot; including mitral annulus, central fibrous body, membranous septum, base of the aorta, and crest of the ventricular septum. Lev disease has an onset about the fourth decade and is believed to be secondary to wear and tear on these structures caused by the pull of the left ventricular musculature. It affects the proximal bundle branches and is manifested by bradycardia and varying degrees of AV block. Lenègre disease: This is an idiopathic, fibrotic degenerative disease restricted to the His-Purkinje system. It is caused by fibrocalcareous changes in mitral annulus, membranous septum, aortic valve, and crest of the ventricular septum. These degenerative and sclerotic changes are not attributed to inflammatory or ischemic involvement of adjacent myocardium. Lenègre disease involves the middle and distal portions of both bundle branches and affects a younger population than Lev disease. Idiopathic degenerative diseases of the conduction system Lev disease: This is due to progressive degenerative fibrosis and calcification of the neighboring cardiac structures, &amp;quot;sclerosis of the left side of cardiac skeleton,&amp;quot; including mitral annulus, central fibrous body, membranous septum, base of the aorta, and crest of the ventricular septum. Lev disease has an onset about the fourth decade and is believed to be secondary to wear and tear on these structures caused by the pull of the left ventricular musculature. It affects the proximal bundle branches and is manifested by bradycardia and varying degrees of AV block. Lenègre disease: This is an idiopathic, fibrotic degenerative disease restricted to the His-Purkinje system. It is caused by fibrocalcareous changes in mitral annulus, membranous septum, aortic valve, and crest of the ventricular septum. These degenerative and sclerotic changes are not attributed to inflammatory or ischemic involvement of adjacent myocardium. Lenègre disease involves the middle and distal portions of both bundle branches and affects a younger population than Lev disease. Idiopathic degenerative diseases of the conduction system Lev disease: This is due to progressive degenerative fibrosis and calcification of the neighboring cardiac structures, &amp;quot;sclerosis of the left side of cardiac skeleton,&amp;quot; including mitral annulus, central fibrous body, membranous septum, base of the aorta, and crest of the ventricular septum. Lev disease has an onset about the fourth decade and is believed to be secondary to wear and tear on these structures caused by the pull of the left ventricular musculature. It affects the proximal bundle branches and is manifested by bradycardia and varying degrees of AV block. Lenègre disease: This is an idiopathic, fibrotic degenerative disease restricted to the His-Purkinje system. It is caused by fibrocalcareous changes in mitral annulus, membranous septum, aortic valve, and crest of the ventricular septum. These degenerative and sclerotic changes are not attributed to inflammatory or ischemic involvement of adjacent myocardium. Lenègre disease involves the middle and distal portions of both bundle branches and affects a younger population than Lev disease.
  • ECG: Toxin induced First degree Heart Block

    1. 1. ECG OF THE WEEK M7 UNIT Prof. Dr. P. Vijayaraghavan’s unit By Dr. J. Stalin Roy
    2. 2. Background <ul><li>17 yr old female presented with history of consumption of detergent bleach ‘ala’ (around 50ml) </li></ul><ul><li>Her only complaint was retrosternal and epigastric burning sensation. </li></ul><ul><li>Routine evaluation was done. </li></ul><ul><li>Her ECG is shown in the following slide. </li></ul>
    3. 3. <ul><li>Normal sinus rhythm </li></ul><ul><li>Rate 85, </li></ul><ul><li>Normal P wave, </li></ul><ul><li>PR interval </li></ul><ul><li>Normal QRS axis, morphology, </li></ul><ul><li>ST, T normal, </li></ul><ul><li>QTc = 400/(0.70) ½ = 478ms </li></ul>320ms (0.32sec) ECG taken on the 1 st day
    4. 4. <ul><li>PR interval has normalized to </li></ul>140 ms (0.14 sec) ECG taken on the 3 rd day
    5. 5. <ul><li>This is a rare case presenting with first degree AV block after consuming ‘ALA’ bleach, the main component of which is sodium hypochlorite & amine oxide. </li></ul><ul><li>The block subsided after two days spontaneously probably after complete elimination of the toxin from the body </li></ul><ul><li>There are no previous reports in medical literature implicating hypochlorite in AV blocks. </li></ul>
    6. 6. Sodium hypochlorite poisoning <ul><li>Ingestion of small volumes of sodium hypochlorite causes burns to the mouth and throat, gastrointestinal irritation, nausea and vomiting. </li></ul><ul><li>Aspiration of liquid may lead to pulmonary complications such ARDS. </li></ul><ul><li>Exposure to higher concentrations may lead to tachypnoea, cyanosis, swelling of the airway, and in severe cases, pulmonary oedema and respiratory failure </li></ul><ul><li>Sodium hypochlorite is corrosive and may cause skin blisters. </li></ul><ul><li>Ocular exposure can cause irritation, pain, lacrimation and photophobia. </li></ul>
    7. 7. First-degree AV block <ul><li>First-degree atrioventricular (AV) block is defined as a PR interval exceeding 0.20 seconds. </li></ul>
    8. 8. Causes <ul><li>Athletic training </li></ul><ul><li>Acute MI </li></ul><ul><li>Idiopathic degenerative diseases of the conduction system </li></ul><ul><ul><li>Lev disease </li></ul></ul><ul><ul><li>Lenègre disease </li></ul></ul><ul><li>Drugs: </li></ul><ul><ul><li>Calcium channel blockers, </li></ul></ul><ul><ul><li>Beta-blockers, </li></ul></ul><ul><ul><li>Digoxin, </li></ul></ul><ul><ul><li>Amiodarone </li></ul></ul>
    9. 9. <ul><li>Mitral or aortic valve annulus calcification </li></ul><ul><li>Infectious disease: </li></ul><ul><ul><li>Infective endocarditis, </li></ul></ul><ul><ul><li>Diphtheria, </li></ul></ul><ul><ul><li>Rheumatic fever, </li></ul></ul><ul><ul><li>Chagas disease, </li></ul></ul><ul><ul><li>Lyme disease, </li></ul></ul><ul><ul><li>Tuberculosis </li></ul></ul>
    10. 10. <ul><li>Collagen vascular disease: </li></ul><ul><ul><li>Rheumatoid arthritis </li></ul></ul><ul><ul><li>systemic lupus erythematous </li></ul></ul><ul><ul><li>scleroderma </li></ul></ul><ul><li>Fetuses of pregnant women who are anti-SSA/Ro positive. </li></ul><ul><li>Infiltrative diseases such as amyloidosis or sarcoidosis </li></ul><ul><li>Myotonic dystrophy </li></ul><ul><li>Iatrogenic </li></ul>
    11. 11. <ul><li>Signs </li></ul><ul><ul><li>Asymptomatic at rest. </li></ul></ul><ul><ul><li>Markedly prolonged PR interval may reduce exercise tolerance in patients with left ventricular systolic dysfunction. </li></ul></ul><ul><ul><li>Syncope may result from transient high-degree AV block and in those with infranodal block and wide QRS complex. </li></ul></ul><ul><li>Symptoms </li></ul><ul><ul><li>The intensity of the first heart sound (S1) is decreased in patients with first-degree AV block. </li></ul></ul><ul><ul><li>Patients with first-degree AV block may have a short, soft, blowing, diastolic murmur heard at the cardiac apex. The diastolic murmur is thought to be related to antegrade flow through closing mitral valve leaflets that are stiffer than normal. </li></ul></ul>
    12. 12. Workup <ul><li>Imaging: </li></ul><ul><ul><li>In patients with first-degree AV block and left ventricular systolic dysfunction, Doppler ultrasound may be used to document an improvement in cardiac output during dual-chamber pacing. </li></ul></ul><ul><ul><li>This may provide evidence for the appropriateness of implanting a permanent pacemaker. </li></ul></ul><ul><li>His bundle ECG: </li></ul><ul><ul><li>This is necessary only in patients with symptomatic first-degree AV block and a wide QRS complex. </li></ul></ul><ul><ul><li>Is used to locate the site of the block in these patients. </li></ul></ul><ul><ul><li>As many as 50% of patients show an infranodal conduction delay. </li></ul></ul>
    13. 13. Treatment <ul><li>Patients with asymptomatic first-degree AV block need no treatment </li></ul><ul><li>In patients with symptomatic first-degree AV block medications with potential for AV block must be discontinued if possible. </li></ul><ul><ul><li>Permanent electronic pacemakers may be indicated in those with the following: </li></ul></ul><ul><ul><ul><li>Severe bradycardia </li></ul></ul></ul><ul><ul><ul><li>Syncope associated with infranodal block </li></ul></ul></ul><ul><ul><ul><li>Left ventricular systolic dysfunction, when a shorter AV delay has been shown to improve hemodynamic condition </li></ul></ul></ul><ul><li>Medications </li></ul>
    14. 14. <ul><li>Complications </li></ul><ul><ul><li>Progression to higher degrees of AV block </li></ul></ul><ul><ul><li>Reduction in left ventricular stroke volume and cardiac output </li></ul></ul><ul><ul><li>Pseudo-pacemaker syndrome </li></ul></ul><ul><li>Prognosis </li></ul><ul><ul><li>Isolated first-degree AV block carries no increased risk of mortality. </li></ul></ul><ul><ul><li>Patients with first-degree AV block and infranodal blocks have increased risk of progression to complete AV block. </li></ul></ul>
    15. 15. Pseudo pacemaker syndrome <ul><li>AV dyssynchrony syndrome </li></ul><ul><li>Found in </li></ul><ul><ul><li>Extremely prolonged first-degree AV block </li></ul></ul><ul><ul><li>Nodal rhythm more rapid than the atrial rate, as might occur in children with sinus node dysfunction after congenital defect repair </li></ul></ul><ul><ul><li>Hypertrophic cardiomyopathy with complete AV block </li></ul></ul><ul><li>Due to l oss of physiologic timing of atrial and ventricular contractions resulting in loss of ‘atrial kick’ </li></ul><ul><li>Treatment : </li></ul><ul><ul><li>Treat the AV block </li></ul></ul><ul><ul><li>Some improvement with Atropine </li></ul></ul>
    16. 16. Thank you

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