Diagnostic Image

Silvera Samson Raja,*, Aslesha Vijaay Shethb

aMRCEM Resident, Kauvery Hospital, Chennai, India

bEmergency Care Physician, Kauvery Hospital, Chennai, India

*Correspondence: [email protected] (Dr. Silvera); [email protected] (Dr. Aslesha)

Slip or Block

History

An 89 years aged gentleman, with past history of hypertension and Coronary Artery Disease (CAD), presented to Emergency Department (ED) with an alleged history of accidental fall at a temple while climbing down the stairs. He sustained injury on the right hip and right hand. Patient could not bear body weight since the fall.

Examination

Initial examinations at ED

  1. Airway: Patent and self- maintained
  2. Breathing: RR – 22/min, Spo2 – 96% RA
  3. Normal vesicular breath sounds heard on both sides, equal chest raise on both sides.
  4. Circulation: BP – 140/90 mmHg, HR – 81/min
  5. CVS: S1S2 heard, no murmur, Bilateral peripheral pulses well felt
  6. PA: soft, non-tender, bowel sounds heard
  7. Disability: GCS-E4V5M6, Pupils equal and reacting bilaterally, 3 mm, No focal neurological deficit

Local examination of right leg

  1. Right hip swelling and tenderness (+)
  2. Shortening of right leg
  3. Externally rotated
  4. Range of movement restricted and painful
  5. No distal neuro-vascular deficit

Local examination of right hand

  1. Mild tenderness at Right thenar eminence (+)
  2. Range of movement normal
  3. No distal neuro-vascular deficit, No swelling/redness

Management

  1. Limb immobilized and pain management given
  2. X-ray pelvis with both hips (AP) – No evidence of fracture
  3. X-ray right hand (AP & OBLIQUE) – No evidence of fracture

ECG

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  1. Rate ~90/min
  2. Sinus rhythm
  3. Left axis deviation
    1. PR prolongation of 24 msec. (First Degree AV block)
    2. Incomplete Right bundle branch block.

Complete RBBB is defined by a QRS that is 120 msec or more with rSR in lead V1 and qRS in lead V6. Incomplete RBBB shows the same QRS pattern, but its duration is between 110-120 msec.

Diagnosis: Trifasicular Block

Notes

What is trifasicular block?

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Diagnostic-Image-3

As there is a risk of asystole and syncope in tri-fascicular block, the fall can be either accidental slip or because of impending heart block.

A 48 h Holter monitoring is recommended to investigate the exact reason of fall – whether arrhythmia related or not.

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