Question 18.1

The following ECG (labelled ECG 1) has been sent by fax from a doctor at a small rural hospital seeking advice. The ECG is that of a 78-year-old male presenting with a fractured neck of femur following a fall.


  • List the abnormalities shown on the ECG.
  • What cardiac complication may this patient develop?
  • What advice will you give the rural doctor?

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College Answer


Trifascicular block i.e. 1st degree heart block, left axis deviation, RBBB.


Complete heart block.


Establish cause of fall – mechanical or related to possible syncope. Continued cardiac monitoring. 
Referral to cardiology and transfer to centre with facilities for insertion TPW.


Well, the ECG in the question above is the the canonical ECG from the CICM paper (seeing as they have removed them) but one which I have found on the glorious LITF archive of ECGs.

The moral of the story is that RBBB should not have any axis deviation, so if you see RBBB and the QRS in leads I and aVF is not upright, you must assume there is some sort of fascicle block. A left axis deviation suggests the anterior fascicle has failed; right axis deviation means the posterior fascile is at fault. I have a thing about that.

And yes, these tend to degenerate into complete heart block. In fact the AHA/ACCF/HRS recommend anybody with that much conductive tissue disease get a pacemaker. And they whinge interminably about the inappropriateness of using crudely unscientific terms like "bifascicular" and "trifascicular".

Then, for some reason, the college recommends temporary pacing wires be inserted.

For myself, I cannot understand. Surely, if this patient were transferred to a tertiary hospital, the facilities there would be appropriate for an urgent PPM insertion?

In any case, we all agree he needs a pacemaker so he doesn't break his other hip.