Here are three bounceback cases who presented with recurring syncope
CASE 1: 80yoF presented with syncope, normal labs and the following ECG. Sent home and came back after another syncopal episode
CASE 2: 60yoM presented with syncope, sent home and came back with recurring syncope
CASE 3: 70yoF with syncope, sent home and came back with syncope; sent home with Holter and came back with syncope
All these cases had bundle branch blocks, but what was missed was the additional blocks
- case 1: RBBB + LAFB (LAD, rS inferior, qR high lateral) = bifascicular
- case 2: RBBB + LPFB: (RAD, qR inferior, rS high lateral) = bifascicular
- case 3: LBBB + first degree AV block = trifascicular
In the context of syncope, bifascicular and trifascicular blocks are indications for a pacemaker.
The HEARTS approach to the ECG, includes Heart rate, Electrical conduction, Axis, R-wave, Tension and ST changes. In the context of syncope remember to look for Electrical/Axis changes: if there’s a bundle-branch block look for accompanying fascicle blocks (RBBB should have normal axis; if RAD look for LPFB; if LAD look for LAFB) or AV blocks.
