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Cardiac Bootcamp ECG Challenge

A 58 yo male presents to the Emergency Department with dizziness. His vitals are: HR 48, BP 87/45, RR 20 and Sats 97% on room air. Here is the ECG. What is the diagnosis?
Picture
This is a MOBITZ II 2:1 Block
​
4 Rules to Diagnose a Mobitz Block
​
  1. Are there more P waves than QRS's? Then it may be a Mobitz. Remember that there may also be AV Dissociation with more QRS's than P's. However the most common form we see is the first.
  2. If there are more P's than QRS's , you may also expect the QRS complexes to be clumped.
  3. In order for this to be a block, the P - P Interval must be constant throughout the ECG. If it is not then the cause may be premature atrial contraction. This is because a P is delivered whilst in the relative refractory period and so a QRS is not generated.
  4. If the P-P interval is constant, next look for the P - R interval.
    1. If it is gradually increasing and then a QRS complex is missed, think of Mobitz I, or Wenckebach Block.
      1. Sometimes the best way to work this out is to simply look at the P-R interval immediately after a QRS being dropped. If this P-R interval is shorter than the previous one, then it is a Mobitz I
    2. If the P - R Interval is regular and then a QRS is missed, then this is most likely a Mobitz II block.
    3. If the P - R Interval is irregular, i.e. not consistently increasing or decreasing but random, then it is probably a complete heart block.

CAUSES OF MOBITZ BLOCKS
  • AMI
  • Hyperkalaemia
  • His-Purkinge System Failure below AVN
  • Conduction System Fubrosis
  • Drug related: Amiodarone, Beta blockers, Calcium Channel Blockers, Digoxin
  • Inflammatory/Autoimmune: Myocarditis, Rheumatic Fever, SLE
BEWARE NOT TO MISS THE MOBITZ
There is one particular case where the Mobitz may be missed. This is when the P wave is hidden in the T wave. This may not always be obvious. Remember that the T wave has a smooth and symmetrical shape. If the shape changes from this, then think of a potential P hidden inside a T wave.
​The problem with missing the Mobitz II is that it can deteriorate into a complete heart block.
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