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Bundle Branch Block

Fast & Easy ECGs, 2nd E – A Self-


Paced Learning Program

Fast & Easy ECGs, 2E 1


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Bundle Branches
• Bundle of His divides
into right and left
bundle branches
• Left bundle branch
further divides into
septal, anterior and
posterior fascicles

Fast & Easy ECGs, 2E 2


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Normal QRS Complex
• Narrow – 0.06 to
0.10 seconds in
duration
• Electrical axis is
between 0° and +90°

Fast & Easy ECGs, 2E 3


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Bundle Branch Block
• Leads to one or both
bundle branches
failing to conduct
impulses
• Produces delay in
depolarization of the
ventricle it supplies

Fast & Easy ECGs, 2E 4


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Bundle Branch Block
• Key characteristic are widened
QRS complexes
– 0.12 seconds or greater in
duration
• As such, the first step to
identifying bundle branch
block is to analyze the QRS
complex width
• Next, look at the appearance
of the QRS complexes
– They may be notched,
slurred or M shaped in the
chest leads

Fast & Easy ECGs, 2E 5


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Bundle Branch Block
• Only occurs in supraventricular rhythms
because the impulse originates above the
ventricles and travels down through the
bundle branches in these rhythms

Fast & Easy ECGs, 2E 6


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Bundle Branch Block
• Possible sites of block within the ventricular
conduction system include:
– Right bundle branch (right bundle branch block)
– Left bundle branch (left bundle branch block)
– Left anterior fascicle (left anterior fascicular block),
also called left anterior hemiblock
– Left posterior fascicle (left posterior fascicular block),
also called left posterior hemiblock
– Any combination of these or along with prolongation
of the PR interval (first degree AV block)

Fast & Easy ECGs, 2E 7


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Right Bundle Branch Block (RBBB)
• Conduction
through the right
bundle branch is
blocked causing
delayed right
ventricular
depolarization
• Look for wide, tall,
and notched QRS
complexes in
leads V1, V2 and
slurred S waves in
leads I, V5 and V6
I

Fast & Easy ECGs, 2E 8


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Right Bundle Branch Block

Fast & Easy ECGs, 2E 9


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Causes of Right Bundle Branch Block
• Occurs with anterior wall MI, coronary artery
disease, hypertension, scar tissue that
develops after heart surgery, viral or bacterial
myocarditis and pulmonary embolism
• May also be caused by drug toxicity or be due
to a congenital heart abnormality such as
atrial septal defect

Fast & Easy ECGs, 2E 10


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Left Bundle Branch Block
• Conduction through the
left bundle branch is
blocked, causing
depolarization of the left
ventricle to be delayed
• Look for wide, tall,
notched or slurred QRS
complexes in leads V5, V6
and wide, largely
negative rS complexes or
entirely negative QS
complexes in V1 and V2

Fast & Easy ECGs, 2E 11


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Left Bundle Branch Block

Fast & Easy ECGs, 2E 12


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Causes of Left Bundle Branch Block
• Anterior wall MI, hypertensive heart disease,
aortic stenosis, degenerative changes of the
conduction system or cardiomyopathy

Fast & Easy ECGs, 2E 13


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Repolarization Changes
• Look for wide, tall, notched or slurred QRS
complexes in leads V5, V6
– In RBBB, ST segment depression and T-wave
inversion is seen in leads V1 and V2
– In LBBB, ST segment depression and T-wave
inversion may be seen in most leads, particularly
leads V5 and V6

Fast & Easy ECGs, 2E 14


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Incomplete Bundle Branch Block
• Sometimes either the right or
left bundle branch conducts the
electrical impulse more slowly
but it is not completely blocked
• Results in QRS complexes with a
similar appearance to bundle
branch block and slightly wider
than normal but not as wide as
with complete bundle branch
block
– duration is no greater 0.11 seconds

Fast & Easy ECGs, 2E 15


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Hemiblocks
• Occur when one or more of the LBB fascicles is
blocked
• While the ECG appearance of anterior and
posterior hemiblocks differs from that of bundle
branch blocks, the mechanism is essentially the
same
• Minimal prolongation with hemiblock, it is not
enough to widen the QRS complex to any real
degree but the morphology of the QRS complex
does change I

Fast & Easy ECGs, 2E 16


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Hemiblocks
• Axis deviation is the key ECG characteristic of
hemiblocks
– It occurs because when one fascicle is blocked, the
electrical current travels down the other to
stimulate the heart. This causes the axis to shift
accordingly
• When diagnosing hemiblock, be sure to rule
out other causes of axis deviation, such as
ventricular hypertrophy
Fast & Easy ECGs, 2E 17
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Hemiblocks
• The anterior fascicle is longer and thinner and
has a more fragile blood supply than the
posterior fascicle, so LAHB is far more
common than LPHB
• While LAHB can be seen in both normal and
diseased hearts, LPHB is almost always
associated with heart disease

Fast & Easy ECGs, 2E 18


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Left Anterior Hemiblock
• Conduction down the left
anterior fascicle is blocked
• Depolarization of the left
ventricle occurs,
progressing in an inferior-
to-superior and right-to-
left direction
• The axis of ventricular
depolarization is
redirected upward and
slightly to the left,
producing tall positive R
waves in the left lateral
leads and deep S waves
inferiorly resulting in left
axis deviation I

Fast & Easy ECGs, 2E 19


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Left Posterior Hemiblock
• Conduction down left
posterior fascicle is blocked
• Electrical impulse rushes
down left anterior fascicle,
resulting in ventricular
myocardial depolarization
occurring in a superior-to-
inferior and left-to-right
direction
• Main electrical axis is
directed downward and to
the right, producing tall R
waves inferiorly and deep S
waves in left lateral leads
resulting in right axis
deviation I

Fast & Easy ECGs, 2E 20


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Combination of Blocks
• Patients with any type of ventricular
conduction block and especially those with a
combination of blocks are at high risk of
developing complete heart block

Fast & Easy ECGs, 2E 21


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Bifascicular Block
• Is a conduction disturbance in which two of
the three main fascicles of the His/Purkinje
system are blocked
– Most often, it refers to a combination of RBBB and
either LAHB (more commonly) or LPHB
– Some include LBBB in the definition of bifascicular
block because the block occurs above the
bifurcation of the left anterior and left posterior
fascicles of the left bundle branch

Fast & Easy ECGs, 2E 22


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Trifascicular Block
• Is a conduction
disturbance in which
there are three features
seen on the ECG such
as:
– Prolongation of the PR
interval (first degree AV
block)
– RBBB
– Either LAFB or LPFB
• Is uncommon

Fast & Easy ECGs, 2E 23


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Practice Makes Perfect
• Determine the condition

Fast & Easy ECGs, 2E 24


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Practice Makes Perfect
• Determine the condition

Fast & Easy ECGs, 2E 25


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Practice Makes Perfect
• Determine the condition

Fast & Easy ECGs, 2E 26


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Practice Makes Perfect
• Determine the condition

Fast & Easy ECGs, 2E 27


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Practice Makes Perfect
• Determine the condition

Fast & Easy ECGs, 2E 28


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Practice Makes Perfect
• Determine the condition

Fast & Easy ECGs, 2E 29


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Practice Makes Perfect
• Identify this condition

Fast & Easy ECGs, 2E 30


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Summary
• Bundle branch block is a disorder that leads to
one or both of the bundle branches failing to
conduct impulses. This produces a delay in the
depolarization of the ventricle it supplies
• In bundle branch block a widened QRS complex is
seen in the chest leads. It may be tall and
notched or slurred and/or have an “M” shaped
appearance
• To diagnose right bundle branch block look for
wide, tall, and notched QRS complexes in leads
V1, V2 and slurred S waves in leads I, V5 and V6

Fast & Easy ECGs, 2E 31


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Summary
• To diagnose left bundle branch block Look for wide, tall,
notched or slurred QRS complexes in leads V5, V6
• Sometimes an R, R’ wave is seen in a QRS complex of
normal duration. This is called incomplete bundle branch
block
• Similar to the repolarization abnormalities seen in
hypertrophy, so too can these changes be seen in both
RBBB and LBBB
• If only a portion of the left bundle branch is blocked, it is
called a fascicular block
• Hemiblocks cause axis deviation. LAHB results in left axis
deviation. LPHB results in right axis deviation
• Bundle branch block often does not require treatment

Fast & Easy ECGs, 2E 32


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Summary
• Bifascicular block is a conduction disturbance in which
two of the three main fascicles of the His/Purkinje system
are blocked
– Most often, it refers to a combination of RBBB and
either LAHB (more commonly) or LPHB
• Trifascicular block is a conduction disturbance in which
there are three features seen on the ECG:
– Prolongation of the PR interval (first degree AV block)
– RBBB
– Either LAFB or LPFB

Fast & Easy ECGs, 2E 33


© 2013 The McGraw-Hill Companies, Inc. All rights reserved.