Ashman Phenomenon, by my understanding, is when a patient in Atrial Fibrillation has a long R to R interval followed by a relatively short R to R interval. During the long R to R, I guess the corresponding refractory period is also lengthened, to the point where it isn't quite finished by the next beat, causing aberrant conduction, typically mirroring a Right Bundle Branch Block, but sometimes other patterns too.
I originally stated that the patient had A.fib with occasional aberrant conduction, which appeared to be a Right Bundle Branch Block.
I dug up the 12 lead that I saved and I saw that it didn't appear to be a right bundle branch block, but in fact a left bundle branch block.
But enough talk, here are 2 of the EKGs I did....
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| Ignore the Wandering Baseline... |
I guess Ashman phenomenon is occasionally mistook for a PVC, but seeing as how this patient had multiple perfusing abnormal beats in a row at a reasonable rate, it seemed more like a block.
Lead II in monitor mode wasn't very useful in showing the aberrant beats(they barely registered as squiggles), in retrospect I could've used MCL1, that might have shown the rhythm better, but I guess that will have to wait for next time.
It is interesting though, because what I read about Ashman Phenomena on the internet (the source of all credible information) it seems to usually just be a single beat. But if this patient's heart couldn't refract (Is a word, no?) fast enough, I guess it would make sense for multiple beats in a row to conduct abnormally.
Now my question for discussion would be, Did this patient prescription to Diltiazem increase her aberrant beats or not?
Any comments?
Actually, in Ashman's you get RBBB conduction. The wide beats in these ECG's have LBBB morphology, so this is not Ashman's.
ReplyDeleteIt looks like you have a progressive decrease in conduction of the left bundle branches. You can see the beats getting wider and wider until they conduct with a full left bundle branch block. After the long pause the left bundle can conduct normally. This is a fairly ominous sign in my opinion, without seeing his previous ECG I would assume in the field that this is related to ischemia.
As for Dilt being the cause, I wouldn't imagine it to be the case. Perhaps if this was a recent change, but I'd expect bradycardia and hypotension.
In an email exchange with other ECG aficionados (read: nerds) I was corrected in my statement that Ashman's only conducts with RBBB, when in fact it could conduct with either.
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Either way, I would have much preferred "sinus rhythm with no ST changes/abnormalities" as my first 12 lead as a Medic, but I guess we can't have everything.
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