Question 30.3

Report on the abnormalities on the following ECG:

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College Answer

Right bundle branch block

Q waves in leads II III and AVF and T wave inversion in III and AVF indicative of old inferior infarct

>2 mm ST segment elevation in leads V2 and V3 and ST elevation in leads V4 and V5 indicating STEMI


As the above ECG was combed out of random Google searches rather than CICM gospel, it does not contain Q waves.

It is, however, an example of RBBB with an anterior STEMI.

A vigorous discussion of the difficulties of this diagnosis (given that anteriorly the T waves are "apropriately discordant" in RBBB) occurs at the EMS12Lead blog. In short, the key seems to be to find the J-point (the transition from QRS into ST) and to demonstrate that it is above the isoelectric line


Pelter, Michele M., and Mary G. Adams. "ST segment changes in right bundle branch block." American Journal of Critical Care 14.4 (2005): 341-342.