Understanding AV Blocks

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Questions and Answers

What is an AV block?

Arrhythmia where there is a delayed or failed conduction of impulses to the ventricles; occurs in AV node, bundle of His or bundle branches

In an AV block, the QRS complexes will be of _____ duration if the block is located at the level of the AV node or bundle of His.

normal

In an AV block, the QRS complexes will be of _____ duration if the block is located at the level of the bundle branches.

longer

What is a first-degree AV block?

<p>AV block classification system - impulses are delayed in AV node, but all are conducted to the ventricles</p> Signup and view all the answers

What is a second-degree AV block?

<p>AV block classification system - some impulses are conducted to the ventricles and some are blocked</p> Signup and view all the answers

What component of the ECG is key to identifying the type (degree) of block present?

<p>PR interval</p> Signup and view all the answers

What two components of the ECG are key to identifying the location of block present?

<p>Width of QRS, ventricular rate</p> Signup and view all the answers

What are the characteristics of first-degree AV block?

<p>CHARACTERISTICS: consistently prolonged PR interval, normal duration QRS, identified with underlying rhythm</p> Signup and view all the answers

Where is the location of the conduction disorder in a first-degree AV block?

<p>AV node</p> Signup and view all the answers

Identify this strip: Sinus bradycardia with AV block

<p>sinus bradycardia with first-degree AV block</p> Signup and view all the answers

Identify this strip: NSR with AV block

<p>NSR with first-degree AV block</p> Signup and view all the answers

Identify this strip: Sinus arrhythmia with AV block

<p>sinus arrhythmia with first-degree AV block</p> Signup and view all the answers

This arrhythmia is associated with inferior wall MI, increased vagal tone, drug effects (calcium channel blockers, beta blockers, and digitalis), hyperkalemia, and degenerative changes due to aging.

<p>first-degree AV block</p> Signup and view all the answers

This arrythmia does not require any specific treatment but should be observed for progression to more serious block.

<p>first-degree AV block</p> Signup and view all the answers

What is also known as Wenckebach?

<p>Mobitz I (second-degree AV block)</p> Signup and view all the answers

What are the characteristics of Mobitz I (second-degree AV block)?

<p>CHARACTERISTICS: progressively longer PR intervals until QRS is dropped and pause follows, cycle repeats itself, irregular ventricular rate, normal QRS duration</p> Signup and view all the answers

Where is the conduction disorder located in Mobitz I (second-degree AV block)?

<p>AV node</p> Signup and view all the answers

Identify this strip: Mobitz I AV block

<p>Mobitz I (second-degree AV block)</p> Signup and view all the answers

This arrhythmia is associated with inferior wall MI, increased vagal tone, effects of medications (calcium channel blockers, beta blockers, and digitalis), and hyperkalemia.

<p>Mobitz I (second-degree AV block)</p> Signup and view all the answers

This arrhythmia may progress to higher degree of AV block under certain conditions, but generally not the case.

<p>Mobitz I (second-degree AV block)</p> Signup and view all the answers

This arrhythmia is usually temporary and resolves spontaneously.

<p>Mobitz I (second-degree AV block)</p> Signup and view all the answers

What two components of the strip are used to differentiate between Mobitz I and nonconducted PAC?

<p>P waves, P-P regularity</p> Signup and view all the answers

MOBITZ I/NONCONDUCTED PAC: abnormal p-wave/different from sinus beats

<p>nonconducted PAC</p> Signup and view all the answers

MOBITZ I/NONCONDUCTED PAC: occurs prematurely; P-P regularity interrupted

<p>nonconducted PAC</p> Signup and view all the answers

MOBITZ I/NONCONDUCTED PAC: P wave is normal/same as sinus beats

<p>Mobitz I</p> Signup and view all the answers

MOBITZ I/NONCONDUCTED PAC: P wave occurs on time; P-P regularity unchanged

<p>Mobitz I</p> Signup and view all the answers

MOBITZ I/NONCONDUCTED PAC: PR interval of basic rhythm varies

<p>Mobitz I</p> Signup and view all the answers

MOBITZ I/NONCONDUCTED PAC: PR interval of basic rhythm remains constant

<p>nonconducted PAC</p> Signup and view all the answers

Identify this strip: Mobitz I pattern with dropped beats

<p>Mobitz I</p> Signup and view all the answers

Identify this strip: Premature P wave with no QRS complex

<p>nonconducted PAC</p> Signup and view all the answers

This arrhythmia is usually asymptomatic and requires no tx; if Pt is symptomatic and ventricular rate is slow, symptomatic bradycardia protocols should be followed (atropine!); discontinue drugs causing block

<p>Mobitz I (second-degree AV block)</p> Signup and view all the answers

What is characterized by failure of some sinus impulses to be conducted to the ventricles?

<p>Mobitz II (second-degree AV block)</p> Signup and view all the answers

In what two places can the conduction disorder be located in a Mobitz II (second-degree AV block)?

<p>bundle of His, bundle branches</p> Signup and view all the answers

If the block is located in the bundle of His in Mobitz II (second-degree AV block), the QRS complex will be of _____ duration.

<p>normal</p> Signup and view all the answers

If the block is located in the bundle branches in Mobitz II (second-degree AV block), the QRS complex will be of _____ duration.

<p>longer</p> Signup and view all the answers

Identify this strip: 2:1 AV conduction block

<p>Mobitz II with 2:1 AV conduction</p> Signup and view all the answers

Identify this strip: 2:1 and 3:1 AV conduction block

<p>Mobitz II with 2:1 and 3:1 AV conduction</p> Signup and view all the answers

This arrhythmia has the potential to progress suddenly to third-degree AV block or ventricular standstill with little to no warning.

<p>Mobitz II (second-degree AV block)</p> Signup and view all the answers

This arrhythmia is associated with anterior wall MI, acute myocarditis, degeneration of electrical conduction system as seen in the elderly, and Stokes-Adams attacks.

<p>Mobitz II (second-degree AV block)</p> Signup and view all the answers

What are syncopal episodes associated with Mobitz II and 3rd degree AV block

<p>Stokes-Adams attacks</p> Signup and view all the answers

What is the treatment for Mobitz II (second-degree AV block) and third-degree AV block?

<p>Mobitz II (second-degree AV block), third-degree AV block</p> Signup and view all the answers

True or False: Atropine is not recommended for treatment of Mobitz II (second-degree AV block) or third-degree AV block.

<p>True (A)</p> Signup and view all the answers

In a third-degree AV block, the _____ are usually paced by the sinus node.

<p>atria</p> Signup and view all the answers

In a third-degree AV block, the _____ are usually paced by a junctional or ventricular pacemaker site.

<p>ventricles</p> Signup and view all the answers

In what three places can the conduction disorder be located in a third-degree AV block?

<p>AV node, bundle of His, bundle branches</p> Signup and view all the answers

If the block is located in the AV node or bundle of His in third-degree AV block, the QRS complex will be of _____ duration.

<p>normal</p> Signup and view all the answers

If the block is located in the bundle branches in third-degree AV block, the QRS complex will be of _____ duration.

<p>longer</p> Signup and view all the answers

Identify this strip: Independent P waves and QRS complexes

<p>third-degree AV block</p> Signup and view all the answers

This arrhythmia has the potential to progress suddenly to ventricular standstill with little to no warning.

<p>third-degree AV block</p> Signup and view all the answers

This arrhythmia is associated with inferior wall or anterior wall MI, Lyme disease, digitalis toxicity, degeneration of electrical conduction system, and Stokes-Adams attacks.

<p>third-degree AV block</p> Signup and view all the answers

In a third-degree AV block with _____ wall MI is usually stable and resolves on its own.

<p>inferior</p> Signup and view all the answers

In a third-degree AV block with _____ wall MI is usually unstable and may require permanent pacing.

<p>anterior</p> Signup and view all the answers

Describe a first-degree AV block.

<p>Impulses are delayed in the AV node, but all are conducted to the ventricles.</p> Signup and view all the answers

Describe a second-degree AV block.

<p>Some impulses are conducted to the ventricles and some are blocked.</p> Signup and view all the answers

List the characteristics of first-degree AV block.

<p>Consistently prolonged PR interval, normal duration QRS, identified with underlying rhythm</p> Signup and view all the answers

Identify this strip: sinus bradycardia with first-degree AV block.

<p>sinus bradycardia with first-degree AV block</p> Signup and view all the answers

Identify this strip: NSR with first-degree AV block.

<p>NSR with first-degree AV block</p> Signup and view all the answers

Identify this strip: sinus arrhythmia with first-degree AV block.

<p>sinus arrhythmia with first-degree AV block</p> Signup and view all the answers

First-degree AV block is associated with what conditions?

<p>Inferior wall MI, increased vagal tone, drug effects (calcium channel blockers, beta blockers, and digitalis), hyperkalemia, and degenerative changes due to aging</p> Signup and view all the answers

Does first-degree AV block require any specific treatment?

<p>No, but the patient should be observed for progression to more serious block</p> Signup and view all the answers

What is Mobitz I (second-degree AV block)?

<p>Aka Wenckebach; sinus impulse is normally conducted to AV node but each successive impulse has increasing difficulty passing through AV node until an impulse does not pass/not conducted</p> Signup and view all the answers

List the characteristics of Mobitz I (second-degree AV block).

<p>Progressively longer PR intervals until QRS is dropped and pause follows, cycle repeats itself, irregular ventricular rate, normal QRS duration</p> Signup and view all the answers

Identify this strip: Mobitz I (second-degree AV block).

<p>Mobitz I (second-degree AV block)</p> Signup and view all the answers

Mobitz I (second-degree AV block) is associated with what conditions?

<p>Inferior wall MI, increased vagal tone, effects of medications (calcium channel blockers, beta blockers, and digitalis), and hyperkalemia</p> Signup and view all the answers

Can Mobitz I (second-degree AV block) progress to higher degree of AV block?

<p>May progress to higher degree of AV block under certain conditions, but generally not the case</p> Signup and view all the answers

How long does Mobitz I (second-degree AV block) typically last?

<p>Usually temporary and resolves spontaneously</p> Signup and view all the answers

Identify this strip: Mobitz I.

<p>Mobitz I</p> Signup and view all the answers

Identify this strip: nonconducted PAC.

<p>nonconducted PAC</p> Signup and view all the answers

In general, does Mobitz I (second-degree AV block) require treatment?

<p>Usually asymptomatic and requires no tx; if Pt is symptomatic and ventricular rate is slow, symptomatic bradycardia protocols should be followed (atropine!); discontinue drugs causing block</p> Signup and view all the answers

Identify this strip: Mobitz II with 2:1 AV conduction.

<p>Mobitz II with 2:1 AV conduction</p> Signup and view all the answers

Identify this strip: Mobitz II with 3:1 AV conduction (one P wave hidden in T waves).

<p>Mobitz II with 3:1 AV conduction (one P wave hidden in T waves)</p> Signup and view all the answers

Identify this strip: Mobitz II with 2:1 and 3:1 AV conduction.

<p>Mobitz II with 2:1 and 3:1 AV conduction</p> Signup and view all the answers

Can Mobitz II (second-degree AV block) progress to a more serious AV block?

<p>This arrhythmia has the potential to progress suddenly to third-degree AV block or ventricular standstill with little to no warning</p> Signup and view all the answers

What are Stokes-Adams attacks?

<p>syncopal episodes associated with Mobitz II and 3rd degree AV block</p> Signup and view all the answers

How is Mobitz II (second-degree AV block) treated?

<p>Treatment usually involves pacemaker therapy due to permanence and high likelihood of progressing; symptomatic Pts will receive external pacing until transvenous pacing can be used; unresolved requires permanent pacemaking</p> Signup and view all the answers

T/F: Atropine is not recommended for treatment of Mobitz II (second-degree AV block) or third-degree AV block.

<p>True (A)</p> Signup and view all the answers

Identify this strip: third-degree AV block.

<p>third-degree AV block</p> Signup and view all the answers

Can third-degree AV block progress to a more serious condition?

<p>this arrhythmia has the potential to progress suddenly to ventricular standstill with little to no warning</p> Signup and view all the answers

Describe Mobitz I (second-degree AV block).

<p>Aka Wenckebach; sinus impulse is normally conducted to AV node but each successive impulse has increasing difficulty passing through AV node until an impulse does not pass/not conducted</p> Signup and view all the answers

How is a Mobitz II (second-degree AV block) characterized?

<p>Characterized by failure of some sinus impulses to be conducted to the ventricles</p> Signup and view all the answers

What is the treatment usually for Mobitz II (second-degree AV block) or third-degree AV block?

<p>treatment usually involves pacemaker therapy due to permanence and high likelihood of progressing; symptomatic Pts will receive external pacing until transvenous pacing can be used; unresolved requires permanent pacemaking (2 answers!)</p> Signup and view all the answers

Atropine is recommended for treatment of Mobitz II (second-degree AV block) or third-degree AV block.

<p>False (B)</p> Signup and view all the answers

Flashcards

AV block

Arrhythmia characterized by delayed or failed conduction of impulses to the ventricles, occurring in the AV node, bundle of His, or bundle branches.

Normal QRS duration in AV block

In AV block, QRS complexes are of normal duration when the block is in the AV node or bundle of His.

Longer QRS duration in AV block

In AV block, QRS complexes are longer in duration when the block is located at the level of the bundle branches.

First-degree AV block

Impulses are delayed in the AV node, but all are conducted to the ventricles.

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Second-degree AV block

Some impulses are conducted to the ventricles, and some are blocked.

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Third-degree AV block

All impulses are blocked, and none are conducted to the ventricles.

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PR Interval in AV Block Identification

The PR interval is key to identifying the type (degree) of block present.

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QRS Width and Ventricular Rate

The width of the QRS complex and the ventricular rate help to identify the location of the block.

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First-degree AV block

Mildest form of AV block. Impulses originate in the sinus node and travel to the AV node where it's delayed longer than usual. Each impulse is still conducted to the ventricles.

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First-degree AV block characteristics

Consistently prolonged PR interval, normal duration QRS, identified with underlying rhythm.

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Location of conduction disorder (1st degree)

The AV node is the location of the conduction disorder.

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Sinus bradycardia with first-degree AV block

Sinus bradycardia with first-degree AV block.

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NSR with first-degree AV block

NSR with first-degree AV block.

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NSR with first-degree AV block

NSR with first-degree AV block.

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Sinus arrhythmia with first-degree AV block

Sinus arrhythmia with first-degree AV block.

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Associated conditions (First-degree AV block)

This arrhythmia is associated with inferior wall MI, increased vagal tone, drug effects (calcium channel blockers, beta blockers, and digitalis), hyperkalemia, and degenerative changes due to aging.

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Treatment (First-degree AV block)

This arrhythmia does not require any specific treatment but should be observed for progression to more serious block.

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Mobitz I (second-degree AV block)

Sinus impulse is normally conducted to the AV node, but each successive impulse has increasing difficulty passing through until an impulse does not pass/not conducted.

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Mobitz I (second-degree AV block) characteristics

Progressively longer PR intervals until QRS is dropped and pause follows, cycle repeats itself, irregular ventricular rate, normal QRS duration.

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Location of conduction disorder (Mobitz I)

The AV node is the location of the conduction disorder.

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Mobitz I (second-degree AV block)

Mobitz I (second-degree AV block).

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Mobitz I (second-degree AV block)

Mobitz I (second-degree AV block).

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Mobitz I (second-degree AV block)

Mobitz I (second-degree AV block).

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Mobitz I (second-degree AV block)

Mobitz I (second-degree AV block).

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Associated conditions (Mobitz I)

This arrhythmia is associated with inferior wall MI, increased vagal tone, effects of medications (calcium channel blockers, beta blockers, and digitalis), and hyperkalemia.

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Progression risk (Mobitz I)

This arrhythmia may progress to a higher degree of AV block under certain conditions, but generally not the case.

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Resolution nature (Mobitz I)

This arrhythmia is usually temporary and resolves spontaneously.

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Differentiation between Mobitz I and PAC

P waves and P-P regularity are used to differentiate between Mobitz I and nonconducted PAC.

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Nonconducted PAC

Abnormal p-wave/different from sinus beats.

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Nonconducted PAC

Occurs prematurely; P-P regularity interrupted.

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Mobitz I

P wave is normal/same as sinus beats.

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Mobitz I

P wave occurs on time; P-P regularity unchanged.

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Mobitz I

PR interval of basic rhythm varies.

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Nonconducted PAC

PR interval of basic rhythm remains constant.

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Mobitz I

Mobitz I

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nonconducted PAC

nonconducted PAC

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Treatment (Mobitz I)

This arrhythmia is usually asymptomatic and requires no treatment; if the patient is symptomatic and the ventricular rate is slow, symptomatic bradycardia protocols should be followed (atropine!); discontinue drugs causing block.

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Mobitz II (second-degree AV block)

Characterized by the failure of some sinus impulses to be conducted to the ventricles.

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Mobitz II (second-degree AV block) characteristics

More than one P wave per QRS complex with only one impulse being conducted (2:1, 3:1, etc conduction ratios), consistent PR intervals with no progressive increase.

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Location of conduction disorder (Mobitz II)

The block can be located in the bundle of His, or bundle branches.

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QRS (Mobitz II - bundle of His)

If the block is located in the bundle of His, the QRS complex will be of normal duration.

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QRS (Mobitz II - bundle branches)

If the block is located in the bundle branches, the QRS complex will be of longer duration.

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Mobitz II with 2:1 AV conduction

Mobitz II with 2:1 AV conduction.

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Mobitz II with 3:1 AV conduction

Mobitz II with 3:1 AV conduction (one P wave hidden in T waves).

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Mobitz II with 2:1 and 3:1 AV conduction

Mobitz II with 2:1 and 3:1 AV conduction.

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Mobitz II with 2:1 and 4:1 AV conduction.

Mobitz II with 2:1 and 4:1 AV conduction.

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Progression risk (Mobitz II)

This arrhythmia has the potential to progress suddenly to third-degree AV block or ventricular standstill with little to no warning.

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Associated conditions (Mobitz II)

This arrhythmia is associated with anterior wall MI, acute myocarditis, degeneration of the electrical conduction system as seen in the elderly, and Stokes-Adams attacks.

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Stokes-Adams attacks

Syncopal episodes associated with Mobitz II and 3rd degree AV block.

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Treatment (Mobitz II)

Treatment usually involves pacemaker therapy due to permanence and a high likelihood of progressing; symptomatic Pts will receive external pacing until transvenous pacing can be used; unresolved cases require permanent pacemaking.

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Study Notes

  • AV block is an arrhythmia characterized by delayed or failed conduction of impulses to the ventricles.
  • AV blocks can occur in the AV node, bundle of His, or bundle branches.
  • ECG components key to identifying blocks include the PR interval, width of the QRS complex, and ventricular rate.

QRS Complex Duration

  • Normal QRS duration suggests the block is at the AV node or bundle of His.
  • A longer QRS duration indicates the block is located at the level of the bundle branches.

AV Block Classification System

  • First-degree AV block: Impulses are delayed in the AV node, but all are eventually conducted to the ventricles.
  • Second-degree AV block: Some impulses are conducted to the ventricles, while others are blocked.
  • Third-degree AV block: No impulses are conducted to the ventricles.

First-Degree AV Block

  • Mildest form of AV block where the impulse originates in the sinus node and is delayed longer than usual in the AV node, but is still conducted to the ventricles.
  • Consistent prolonged PR interval and normal QRS duration are characteristic of this arrhythmia.
  • Underlying rhythm identification is key.
  • May be associated with inferior wall MI, increased vagal tone, drug effects (calcium channel blockers, beta blockers, and digitalis), hyperkalemia, and degenerative changes due to aging.
  • Typically requires no specific treatment but warrants observation for progression.
  • Location of the conduction disorder is in the AV node.
  • Examples of rhythms with first-degree AV block include sinus bradycardia, normal sinus rhythm (NSR), and sinus arrhythmia.

Second-Degree AV Block: Mobitz I (Wenckebach)

  • Each successive impulse has increasing difficulty passing through the AV node until an impulse is blocked.
  • Progressively longer PR intervals until a QRS complex is dropped, followed by a pause, and the cycle repeats.
  • Irregular ventricular rate and normal QRS duration are typical.
  • Conduction disorder is located in the AV node.
  • Related to inferior wall MI, increased vagal tone, certain medications (calcium channel blockers, beta blockers, digitalis), and hyperkalemia.
  • Generally temporary and typically resolves spontaneously but may progress to a higher degree of AV block under certain conditions.

Distinguishing Mobitz I from Nonconducted PACs

  • Mobitz I: P wave is normal/same as sinus beats, occurs on time, P-P regularity unchanged, PR interval of basic rhythm varies
  • Nonconducted PAC: abnormal p-wave/different from sinus beats, occurs prematurely; P-P regularity interrupted, PR interval of basic rhythm remains constant
  • Usually asymptomatic and may not require treatment; symptomatic patients with slow ventricular rates should follow symptomatic bradycardia protocols (atropine), and discontinue causative drugs.

Second-Degree AV Block: Mobitz II

  • Some sinus impulses fail to conduct to the ventricles.
  • Presence of more than one P wave per QRS complex, indicating conduction ratios such as 2:1 or 3:1.
  • PR intervals remain consistent with no progressive increase.
  • Conduction disorder can be located in the bundle of His or bundle branches.
  • Normal QRS duration suggests a block in the bundle of His, while longer QRS duration indicates a block in the bundle branches.
  • Has the potential to progress suddenly to third-degree AV block or ventricular standstill.
  • Associated with anterior wall MI, acute myocarditis, degeneration of the electrical conduction system in the elderly, and Stokes-Adams attacks.
  • Treatment often involves pacemaker therapy due to the high risk of progression; external pacing is used for symptomatic patients until transvenous pacing is available; permanent pacemaking is required if unresolved.
  • Atropine is not recommended for Mobitz II.

Stokes-Adams Attacks

  • Syncopal episodes associated with Mobitz II and 3rd degree AV block.

Third-Degree AV Block (Complete Heart Block)

  • No conduction of impulses from the atria to the ventricles.
  • Atria and ventricles beat independently, with no relationship between P waves and QRS complexes.
  • Atria are paced by the sinus node, while ventricles are paced by a junctional or ventricular pacemaker site.
  • P waves appear sporadically across the rhythm strip, may hide within the QRS complex or in the ST segment/T wave, and the PR interval is highly inconsistent.
  • Atrial rate is typically greater than the ventricular rate.
  • Conduction disorder can be located in the AV node, bundle of His, or bundle branches.
  • Normal QRS duration suggests a block in the AV node or bundle of His, while a longer QRS duration indicates a block in the bundle branches.
  • Carries the potential to progress suddenly to ventricular standstill.
  • Associated with inferior or anterior wall MI, Lyme disease, digitalis toxicity, degeneration of the electrical conduction system, and Stokes-Adams attacks.

Third-Degree AV Block and MI Location

  • Third-degree AV block with inferior wall MI is usually stable and resolves on its own.
  • Third-degree AV block with anterior wall MI is generally unstable and may require permanent pacing.

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