Right bundle branch block electrocardiogram: Difference between revisions

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__NOTOC__
__NOTOC__
{{Right bundle branch block}}
{{Right bundle branch block}}
 
{{CMG}}; {{AE}} {{CZ}}
{{CMG}} {{AE}} {{CZ}}


==Overview==
==Overview==
Criteria for complete [[right bundle branch block]] includes: a QRS duration of > .12 seconds, a rSR' pattern with a wide terminal R wave in V1 and a qRS complex with a wide S wave in V6.
Criteria for complete [[right bundle branch block]] include: a QRS duration of > .12 seconds, an rSR' pattern with a wide terminal R wave in V1 and a qRS complex with a wide S wave in V6.


==ECG==
==Electrocardiogram==
===Diagnostic Criteria===
* The heart rhythm must be supraventricular in origin
* The heart rhythm must be supraventricular in origin
* The QRS axis can be either normal, or right or left axis deviation may be present.
* The QRS axis can be either normal, or right or left axis deviation may be present.
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** For complete RBBB, the patient's age must be taken into account to determine if the duration of the QRS complex is prolonged for the patient's age.  
** For complete RBBB, the patient's age must be taken into account to determine if the duration of the QRS complex is prolonged for the patient's age.  
***Maximum QRS durations are 0.07 s for newborns <6 days, 0.08 s for patients aged 1 week to 7 years, and 0.09 s for patients aged 7-15 years.
***Maximum QRS durations are 0.07 s for newborns <6 days, 0.08 s for patients aged 1 week to 7 years, and 0.09 s for patients aged 7-15 years.
* There should be a terminal R wave in lead V1-V3R (e.g., R, rR', rsR', rSR' or qR')
* There should be a terminal R wave in lead V1-V3R (e.g., Rsr', rR', rsR', rSR' or qR')
** This pattern is present because the initial R wave represents septal activation, the S wave represents left ventricular activation, and the R' represents activation of the right ventricle from the septum and left ventricle.
** This pattern is present because the initial [[R wave]] represents septal activation, the S wave represents left ventricular activation, and the R' represents activation of the right ventricle from the septum and left ventricle.
* There should be a slurred S wave in leads I and V6. This represent left ventricular activation.  
* There should be a slurred S wave in leads I and V6. This represent left ventricular activation.  
**  Because transmission of the electrical impulse through the left bundle is normal,  this results in normal depolarization of the septum and the left ventricle. As a result, there is an initial R wave in lead I and V1 and the Q wave in V6.
**  Because transmission of the electrical impulse through the left bundle is normal,  this results in normal depolarization of the septum and the [[left ventricle]]. As a result, there is an initial R wave in lead I and V1 and the Q wave in V6.


The T wave should be deflected opposite the terminal deflection of the QRS complex. This is known as appropriate T wave discordance with bundle branch block. A concordant T wave may suggest [[ischemia]] or [[myocardial infarction]].
The T wave should be deflected opposite the terminal deflection of the QRS complex. This is known as appropriate [[T wave]] discordance with bundle branch block. A concordant T wave may suggest [[ischemia]] or [[myocardial infarction]].


== EKG Examples==
----
EKG below is from an elderly woman who had previously undergone surgery for recurrent ventricular tachycardia. She was being treated with Tambacor and metoprolol. The cardiogram shows sinus rhythm with a wide QRS of 159ms consistent with a RBBB and a rightward axis suggesting right posterior hemi-block. The PR interval is slightly prolonged at 2121ms. The poor R wave progression seen best in lead V2 suggests previous anterior wall MI.
Shown below is an electrocardiogram showing the main characteristics of right bundle branch block on lead V1.


[[Image:Right bundle branch block.jpg|center|800px]]
[[File:Right bundle branch block 3.png|center|300px]]
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
----
----
EKG below is a recording from an older man in the [[surgical intensive care unit]]. He was recovering from a [[motor vehicle accident]] where he sustained a [[chest injury]] from his seat belt. The rhythm is [[sinus rhythm]] with a prolonged p wave duration in lead III( >140ms) and a pronounced terminal negativity in V1 suggestive of left atrial abnormality. The [[QRS]] is wide with a duration of 137ms and a superior and right ward axis. There is an [[RSR]] in V1 and the S wave is greater than the R in V6. This is an unusual pattern for aberrance and is more in keeping with ventricular ectopy. In this case, this appears to be a [[right bundle branch block]] with a possible left posterior hemi-block.
Shown below is an example of an EKG showing sinus rhythm, [[wide QRS]] (>120ms.) and a markedly negative axis. There are small R waves in the inferior leads. The recording shows a right bundle branch block and a [[left anterior fascicular block]].


Of note, in spite of this conduction disturbance the patient was able to sustain reentrant supraventricular tachycaridas requiring intravenous [[adenosine]] for termination.
[[File:Right bundle branch block 2.jpg|center|500px]]


[[Image:Rbbb1.jpg|center|800px]]
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
----
----


{| align="center"
;For EKG examples of right bundle branch block click [[Right bundle branch block EKG examples|here]].
|-valign="top"
| [[Image:RBBB1.png|thumb|The main characteristics of [[Right Bundle Branch Block]] in V1]]
| [[Image:ECG RBTB LAtrD.jpg|thumb|[[Right Bundle Branch Block]]]]
|}
 
 
{| align="center"
|-valign="top"
| [[Image:RBBB.PNG|thumb|[[Right Bundle Branch Block]]]]
| [[Image:C13.ht13.jpg|thumb|[[Right Bundle Branch Block]]]]
|}
 
 
{| align="center"
|-valign="top"
| [[Image:C14.ht14.jpg|thumb|[[Right Bundle Branch Block]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
| [[Image:C15.ht15.jpg|thumb|[[Right Bundle Branch Block]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
|}
 
 
{| align="center"
|-valign="top"
| [[Image:C16.ht16.jpg|thumb|[[Right Bundle Branch Block]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
| [[Image:C17.ht17.jpg|thumb|[[Right Bundle Branch Block]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
|}
 
 
{| align="center"
|-valign="top"
| [[Image:C18.ht18.jpg|thumb|[[Right Bundle Branch Block]] with [[First Degree AV Block|first degree AV block]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
| [[Image:C22.ht22.jpg|thumb|[[Right Bundle Branch Block]] with RA hypertrophy. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
|}
 
 
{| align="center"
|-valign="top"
| [[Image:RBBB_inf_MI.jpg|thumb|Patient with [[RBBB]] and [[Acute MI|inferior MI]]. Note to left axis deviation.]]
| [[Image:RBBB_inf_MI_V4R.jpg|thumb|The same patient. Lead V4R. ST elevation shown.]]
|}
 
 
{| align="center"
|-valign="top"
| [[Image:RBBB_inf_MI_baseline.jpg|thumb|The same patient before [[acute MI]] developed. Horizontal axis shown.]]
| [[Image:R11.ht36.jpg|thumb|[[Supraventricular tachycardia]] with [[RBBB]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
|}
 
 
{| align="center"
|-valign="top"
| [[Image:cominf12.jpg|thumb|Old [[Acute MI|Anterior MI]] with [[RBBB]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
| [[Image:cominf19.jpg|thumb|Old [[Acute MI|Inferior MI]] and [[Acute MI|Anterior MI]] with [[RBBB]] and [[LAFB]].]]
|}
 
 
{| align="center"
|-valign="top"
| [[Image:cominf5.jpg|thumb|Old [[Acute MI|Inferior MI]] and [[RBBB]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
| [[Image:c3.htm3.jpg|thumb|[[RBBB]] + [[LAFB]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
|}
 
 
{| align="center"
|-valign="top"
| [[Image:c19.ht19.jpg|thumb|[[RBBB]] + [[LAFB]] + [[First Degree AV Block]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
| [[Image:c20.ht20.jpg|thumb|[[RBBB]] + [[LAFB]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
| [[Image:c21.ht21.jpg|thumb|[[RBBB]] + [[LPFB]]. <small>  [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>]]
|}
 
==Animation of RBBB==
 
{{#ev:youtube|EJUQKaDeAXg}}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
 
[[Category:Electrophysiology]]
[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
{{WH}}
{{WH}}
{{WS}}
{{WS}}

Latest revision as of 14:55, 12 April 2013

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Criteria for complete right bundle branch block include: a QRS duration of > .12 seconds, an rSR' pattern with a wide terminal R wave in V1 and a qRS complex with a wide S wave in V6.

Electrocardiogram

Diagnostic Criteria

  • The heart rhythm must be supraventricular in origin
  • The QRS axis can be either normal, or right or left axis deviation may be present.
  • The QRS duration must be = or > 120 ms
    • For complete RBBB, the patient's age must be taken into account to determine if the duration of the QRS complex is prolonged for the patient's age.
      • Maximum QRS durations are 0.07 s for newborns <6 days, 0.08 s for patients aged 1 week to 7 years, and 0.09 s for patients aged 7-15 years.
  • There should be a terminal R wave in lead V1-V3R (e.g., Rsr', rR', rsR', rSR' or qR')
    • This pattern is present because the initial R wave represents septal activation, the S wave represents left ventricular activation, and the R' represents activation of the right ventricle from the septum and left ventricle.
  • There should be a slurred S wave in leads I and V6. This represent left ventricular activation.
    • Because transmission of the electrical impulse through the left bundle is normal, this results in normal depolarization of the septum and the left ventricle. As a result, there is an initial R wave in lead I and V1 and the Q wave in V6.

The T wave should be deflected opposite the terminal deflection of the QRS complex. This is known as appropriate T wave discordance with bundle branch block. A concordant T wave may suggest ischemia or myocardial infarction.

Shown below is an electrocardiogram showing the main characteristics of right bundle branch block on lead V1.

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page

Shown below is an example of an EKG showing sinus rhythm, wide QRS (>120ms.) and a markedly negative axis. There are small R waves in the inferior leads. The recording shows a right bundle branch block and a left anterior fascicular block.

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page

For EKG examples of right bundle branch block click here.

References

Template:WH Template:WS

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