A nurse hands you this ECG. The patient had a syncopal episode and is now feeling back to normal.  The syncopal episode was sudden onset at rest without any prodrome or chest pain. Past history of cardiac failure, takes “some fluids for the water and the heart”, (when he remembers to take them), and he lives with his wife.
 

Describe the ECG
 

What is the differential diagnosis and what will you do?
 

This ECG demonstrates trifascicular block

Right bundle branch block
Left axis deviation
+
First degree heart block

Consider this approach:

The best time to check the axis is when you find a right bundle branch block. In fact every time you see a RBBB, it is fairly easy to check for
• first degree heart block [PR > 200msec , five small squares]
• left axis deviation

Assessment and management

• Cardiac monitored bay and IV access
• Bloods
• CXR
• Referral to cardiology team

Consider pacemaker in any patient with trifascicular block and syncope