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7/25/2019 Circulation 1961 HERSCH 853 60
1/9
E l e c t r o c a r d i o g r a p h i c
C h a n g e s
i n
H e a d
I n j u r i e s
Bi
C O L I N
HERSCH,
M L B .
( R A N D ) ,
DI.
M E D .
( R A N D )
T
E
e l e c t r o c a r d i o g r a p h i c
p a t t e r n o f
1 6 4
p a t i e u t s w i t h h e a d
i n j u r y w a s s t u d i e d
a n d c o m p a r e d
w i t h t w o c o n t r o l g r o u p s : 1 0 0
p a t i e n t s w i t h
l i m b
t r a u m a
a u d
1 6 4
h e a l t h y
s u b j e c t s .
I n
t h e
g r o u p
w i t h
t h e h e a d
i n j u r y
t h e
e l e c t r o c a r d i o g r a p h i e
f i n d i n g s w e r e
c o r r e -
l a t e d w i t h t h e l e v e l o f
c o n s c i o u s n e s s .
T h e p o s s i b l e
r e l a t i o n s h i p b e t w e e n h e a d
t r a u m a
a n d
e l e e t r o c a r d i o g r a p h i c c h a n g e s
w a s
f i r s t
s u g g e s t e d
b y
B r a m w e l l . 1
l i e
d e s c r i b e d
a
m i n e r , a g e d 3 5
y e a r s , w h o ,
a f t e r
a b l o w o n i
t h e
h e a d
t h a t
d i d n o t c a u s e
h i m t o l o s e
c o l i -
s c i o u s n e s s , d e v e l o p e d a t r i a l f i b r i l l a t i o n
t h a t
l a s t e d
f o r 4 w e e k s . On
e x a m i n a t i o n o f
t h e
c a r d i o v a s c u l a r a n d c e n t r a l
n e r v o u s s y s t e m s ,
n o t h i u o g
a b n o r m a l
was
f o u n d .
L u c k e 2 d e s c r i b e d
a 5 4 - y e a r - o l d
man
who
f e l l
f r o m
a l a d d e r a n d w a s f o u n d t o
h a v e
b l o c k e d a t r i a l
e x t r a s y s t o l e s
a f t e r
a
l ) e r i o d
o f
c o n c u s s i o n .
I l i s
c a r d i o v a s c u l a r s y s t e m
was
c l i n i c a l l y
n o r n i a l .
D o r e t
a n d
F o r r e r o 3
s t u d i e d
3 2 c a s e s
o f
t r a u m a t i c
e n i e e p h a l o p a t h y
w i t h o u t c l i n i c a l
e v i d e n c e o f
c a r d i o v a s c u l a r
d i s e a s e . T h e y d e -
s c r i b e d v a r i o u s c h a n g e s b u t
d i d
n o t
f i n d a
c h a r a c t e r i s t i c
e l e e t r o c a r d i o g r a p h i c
t r a c i i l w t .
T h e y
d i v i d e d t h e i r c a s e s
i n t o
s i x
' s y m p a -
t h e t i c o t o n i e '
( t a c h y c a r d i a ,
r a i s e d
P
w a v e s
i n
l e a d s
I T
a n d
I I I ,
s h o r t
P-R
i n t e r v a l ,
i n -
c r e a s e d
Q - T
i n t e r v a l ,
a n d
s h a l l o w
T
w a v e s ) ,
f o u r
p a r a s y m ) a t h e t i c o t o n i c
( b r a d y e a r d i a ,
d e p r e s s e d
P
w a v e s , i n c r e a s e d P-R i n t e r v a l ,
s h o r t Q - T
i n t e r v a l ,
a n d t a l l
T w a v e s ) , a n d
2 2
i n t e r m e d i a t e t y p e s .
I n
a d d i t i o n ,
o n e c a s e
h a d v e n t r i c u l a r
e x t r a s v s t o l e s a n d o n e
c a s e
h a d
p a r o x y s m a l
s u p r a v e n t r i e u l a r
t a c h y c a r d i a .
S i n u s r h y t h m
w a s p r e s e n t i n 2 3 e a s e s
a n d
s i n u s
a r r h y t h m i a
i n
n i n e .
N a d a s e t
a l . 4 d e s c r i b e d a 5 - y e a r - o l d
g i r l
who
h a d
a n o r m a l
p u l s e
4
w e e k s
p r i o r
t o a
h e a d
i n j u r y .
S h e
was
u n c o n s c i o u s
f o r
5
m i n -
From
t h e
1 ) e p a r t m e n i t
o f
M e d i c i n e , B a r a g w a I I a t h
H o s p i t a l ,
J o h a n n e s b u r g ,
S o u t h
A f r i c a .
C i r c u l a t i o n ,
Volume
X X I I I ,
June
1 9 6 1
t i e s
a n d a f t e r
t h e i n j u r y d l e v e l o p e d
p a r o x -
s s m a l
v e n t r i c u l a r t a c l h y c a r d i a
c o n f i r m e d
b y
e l e c t r o c a r d i o g r a p h y .
Her
c e n t r a l n e r v o u s
s y s -
t e m a n d c a r d i o v a s c u l a r s y s t e m s
w e r e
e l i n i -
c a l l y i i o r m a l ,
a n d
x - r a y e x a m i n a t i o n
s h o w e d
a f r a c t u r e o f
t h e
b a s e
o f
t h e
s k u l l .
E l e e t r o e a r d i o g r a p h i c
c h a n g e s
h a v e
a l s o
b e e n
n o t e d d u r i n g b r a i n
o p e r a t i o n i s , 5
l u m b a r
p u n c t u r e 0
a n d
p n e u m o e n i e e p h a l o ( r r a p h y , 7
i l l
c e r e b r a l
t u m o r s , 8
p o l i o m n y e l i t i s , 9
a n d i l l
c e r e -
b r a l
h e m o r r h a g e . 1 0
A M u c h e x p e r i m e n t a l w o r k
h a s b e e n p e r -
f o r m e d t o
d e t e r m i n e
t h e r o l e p l a y e d
b y
t h e
c e n t r a l
n e r v o u s s y s t e m n
i l l t h e p r o d u c t i o n
o f
c a r d i a c
i r r e g u l a r i t i e s .
B e a t t i e , B r o w ,
a i i d
L o n ( g 1
p r o d u c e d e x t r a s y s t o l e s
b y s t i m u l a t i o i
o f
t h e
p o s t e r i o r
h y p o t h a l a m n u s
i l l
a i i e s t h e t i z e d
c a t s .
A
d e s t r u c t i v e
l e s i o n
o f t h e
p o s t e r i o r
h y p o t h a l a m u s
o r s e c t i o n
o f t h e
b r a i n b e h i n d
t h i s
l e v e l
c a u s e d t h e s e
e x t r a s y s t o l e s
t o d i s -
a p p e a r .
S t o r n i v a l l L e e u w e n 1 ' 2 o b s e r v e d
n o d a l a n d
v e n t r i c u l a r
r h y t h m i
s h i f t o f t h e s i n i o a t r i a l
l a c e m a k e r ,
a n d
m u l t i f o c a l
e x t r a s y s t o l e s
o n
s t i m u l a t i n g t h e
b r a i n l s
o f c a t s b e t w e e n t h e
l o s t e r i o r
c o r p o r a
q u a d r i g e m i n a
a n d t h e
p o s -
t e r i o r
p o r t i o n s o f t h e c e r e b e l l u m .
E x p e r i m e n t a l s t i m u l a t i o n o f
s u b e o r t i c a l
a r e a s i l l c a t s b y K o r t e w e g e t a l . ' : y i e l d e d t h e
f o l l o w i n i g
r e s u l t s :
S t i m u l a t i o n
o f
t h e
b a s a l
g a n i r l i a
r e s u l t e d
i m n u e d i a t e l y i n o c c a s i o n a l
e x t r a s y s t o l e s .
S t i m n u l a t i o n o f t h e
p o s t e r i o r
h y p o t h a l a m u s a n d t h e
q u a d r i g e m i n a l
b o d i e s
p r o d u c e d v e n t r i c u l a r
e x t r a s y s t o l e s ,
w a n d e r -
i n g
p a c e m a k e r ,
a n d T - w a v e c h a n g e s .
A f t e r
s t i m u l a t i o n h a d c e a s e d , v e n t r i c u l a r
e x t r a s y s -
t o l e s ,
a t r i o v e n t r i e u l a r d i s s o c i a t i o n , w a n d e r i n g
p a c e m a k e r , t a c h y c a r d i a ,
a n d T - w a v e c h a n g e s
w e r e
n o t e d ,
a l l
o f
w h i c h w e r e
a b o l i s h e d b y
v a g a l
s e c t i o n .
A
s t u d y
o f
e l e c t r o c a r d i o g r a p h i c
c h a n g e s
i n
h e a d
trauma was
made b v J a c o b s o n a n d
D a n u f s k v 1 4
i n
1 5 A l b i n o
S w i s s
m i c e .
A l l
t h e
8 5 3
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HERSCH
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w a v e s o f 4
mm. i n
h e i g h t i n
l e a d
I I
a r e
s e e n
i n
A a n d
r e t u r n t o
n o r m a l 9
m o n t h s
l a t e r .
B
a n d C ,
w h i c h w e r e
r e c o r d e d f r o m
t w o
o t h e r
p a t i e n t s ,
a l s o
s h o w
i n c r e a s e d
v o l t a g e o f t h e
P
w a v e
i n
l e a d
I I .
m i c e r e c e i v e d
i n t r a p e r i t o n e a l
t h i o p e n t o n e
p r i o r
t o t h e
t r a u m a ,
a n d
s i x h a d
a t r o p i n e
i n
a d d i t i o n . W i t h i n
2 0
s e c o n d s
a l l
n i n e
a n i -
m a l s
w i t h o u t
a t r o p i n e
d e v e l o p e d
b r a d y e a r d i a ,
i n c r e a s e d
a m p l i t u d e
o f
t h e
T
w a v e ,
a n d a
v a r i e t y
o f
a r r h y t h m i a s - n o d a l
r h y t h m ,
s i n u s
a r r h y t h m i a ,
i n c o m p l e t e
a t r i o v e n t r i c u l a r
b l o c k ,
v e n t r i c u l a r
e x t r a s y s t o l e s ,
a n d
s i n o a t r i a l
b l o c k ;
i n
a d d i t i o n ,
s e v e n
o f
t h e m
s h o w e d
d e c r e a s e d
a m p l i t u d e
o r
i n v e r s i o n
o f
t h e P
w a v e .
I n
t h e
a t r o p i n i z e d
g r o u p , o n
t h e
o t h e r h a n d ,
n o
b r a d y e a r d i a
o c c u r r e d ,
o n e d e v e l o p e d
T - w a v e
a n d
P - w a v e
c h a n g e s ,
a n d
o n e
s h o w e d
a t r i a l
e x t r a s y s t o l e s .
T h e
a u t h o r s
t h e r e f o r e
c o n c l u d e d
t h a t
t h e
e l e c t r o c a r d i o g r a p h i c
c h a n g e s
w e r e
d u e
t o v a g a l
s t i m u l a t i o n . At
a u t o p s y
a l l
t h e
a n i m a l s
h a d
s u b d u r a l
a n d s u b a r a c h n o i d
h e m -
o r r h a g e s , a
f e w h a d
c o r t i c a l
l a c e r a t i o n s
a n d
o n e h a d a n
i n t r a c e r e b r a l
h e m o r r h a g e .
T h e
b r a i n
s t e m s
w e r e
n o r m a l .
I n
t h e
p r e s e n t
p a p e r t h e
e f f e c t
o f
c r a n i o -
c e r e b r a l
t r a u m a
o n
t h e e l e c t r o c a r d i o g r a m
h a s
b e e n
i n v e s t i g a t e d i n
B a n t u
s u b j e c t s .
T a b l e
1
C h a n g e s i n
I n d i v i d u a l
C o m p o n e n t s o f
E l e c t r o c a r d i o g r a m
G r o u p
A
G r o u p
B
G ro up C
P
w a v e
2 . 5
mm.
o r
24
14
2
m o r e
i n
8 2
P - R
i n t e r v a l
m o r e
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0
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t h a n . 2 2
s e c o n d
QRS
c o m p l e x
1 .
I n c o m p l e t e
r i g h t
4
0
0
b u n d l e - b r a n c h
b l o c k
2 .
C o m p l e t e
r i g h t
0
1
0
b u n d l e - b r a n c h
b l o c k
3 .
V o l t a g e
S
i n
V 2
6 5
i n c r e a s e d
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48
i n c r e a s e d
+
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i n
V s *
A v e r a g e
R
+
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m m .
A v e r a g e
R
+
S
=43 m m.
A v e r a g e
R
+S=
3 8
mm.
Q - T e
i n
s e c o n d s t
15
i n c r e a s e d
1
i n c r e a s e d
A l l
n o r m a l
. 2 4 - . 5 4
. 2 9 - . 4 4
( n o r m a l
. 2 4 - . 4 3 )
( n o r m a l . 2 4 - . 4 4 ) ( n o r m a l
. 2 9 - . 4 3 )
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s e g m e n t
r a i s e d
3
more
t h a n 2 . 5
mm .
14
19
i n
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l e a d s
I n v e r t e d
T
waves 10
6
0
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wave
more
t h a n
21
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mm .
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1 . 2 - 4
m m . )
( r a n g e
1 . 2 - 2 . 5
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( 1 . 5
mm.)
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mm.
t Q - T .
m e a s u r e d
b y
t h e m e t h o d
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C i r c u l a t i o n ,
Volume
X X I I I ,
June
1 9 6 1
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3/9
E L E C T R O C A R D I O G R A M
IN
HEAD
I N JURI E S 8 5
F i g u r e
2
A
f i r s t
s h o w s
an
i n c r e a s e i n t h e
Q - T ,
i n t e r v a l .
L a t t e r t h e
Q - T
i n t e r v a l was n o r m a l .
I n
t r a c i n g s f r o m
t w o o t h e r
p a t i e n t s ( B
a n d
C ) l a r g e
U
waves a r e
p r e s e n t ,
b e s t s e e n
i n
V . .
T a b l e 2
A r r h y t h m i a s
G r o u p
A
G r o u p
B
G r o u p
C
S i n u s
A r r h y t h m i a
( a )
f i x e d
p a c e m a k e r
1 0
1
3 % 0
3 0 1
( b )
w a n d e r i n g
p a c e m a k e r
7 13
0
i n
s i n o a t r i a l n o d e
( c ) w a n d e r i n g
p a c e m a k e r
3 0 1
1
0 0 /
t o
a t r i o v e n t r i c u l a r
n o d e
E x t r a s y s t o l e s
6
5 c l
2
N o d a l
r h y t h m
4 0 1
2 1
0
A t r i o v e n t r i c u l a r
b l o c k
1 % /
0
0
T a b l e 3
H e a r t R a t e s
G r o u p
A
G r o u p
B
G r o u p
C
5 9 C a s e s
1 4
C a s e s
4
C a s e s
H e a r t r a t e s
b e t w e e n
5 5
5 3
0
a n d 7 0
p e r
m i n u t e
H e a r t r a t e s
b e t w e e n
7 0
1 8
4
0
a i n d
9 0
p e r
m i n u t e
H e a r t
r a t e s
3 6
7
4
a b o v e
9 0
p e r
m i n u t e
C i r c u l a t i o n ,
Volume
X X I I I ,
June 1 9 6 1
S u b j e c t s
a n d M e t h o d s
T h r e e
g r o u p s
o f
p a t i e n t s
were
s t u d i e d .
G r o u p
A
c o n s i s t e d o f
1 6 4
B a n t u
p a t i e n t s ( 1 5 8
m a l e
a n d
6
f e m a l e )
w i t h
h e a d
i n j u r y ,
who
were
a d m i t t e d
t o
B a r a g w a n a t h H o s p i t a l
o v e r
t h e
p e r i o d
M a r c h
1 9 5 7
t o
M a r c h 1 9 5 8 .
T h e r e were
t w o
c o n t r o l
g r o u p s :
G r o u p
B c o n -
s i s t e d
o f 1 0 0 c o n s e c u t i v e B a n t u
p a t i e n t s
who
s u s t a i n e d t r a u m a
c o n f i n e d
t o
e i t h e r
t h e
u p p e r
o r
l o w e r l i m b s . T h e s e c a s e s
c o m p r i s e d f r a c t u r e s ,
d i s l o c a t i o n s ,
t r a u m a t i c
a m p u t a t i o n s ,
a n d
b u l l e t
w o u n d s . No
p a t i e n t s
were
u n c o n s c i o u s o r
r e q u i r e d
b l o o d t r a n s f u s i o n .
G r o u p
C
was m a d e
up
o f
1 6 4
h e a l t h y
B a n t u
s u b j e c t s
o f
a g e
a n d s e x
d i s t r i b u t i o n
s i m i l a r
t o
g r o u p
A .
A l l t h e
p a t i e n t s
i n
g r o u p
A were u n d e r 4 0
y e a r s
o f
a g e
a n d a l l h a d a
h i s t o r y
o f
i m p a i r e d
c o n s c i o u s n e s s .
I n
no
c a s e was
t h e r e c l i n i c a l
e v i -
d e n c e o f c a r d i o v a s c u l a r d i s e a s e . E l e c t r o c a r d i o -
g r a m s
were
p e r f o r m e d
w i t h i n 1 8
h o u r s
o f
a d m i s s i o n
t o
t h e
h o s p i t a l .
T h e
c a s e s
were
c l a s s i f i e d
i n t o
g r o u p s a c c o r d i n g
t o l e v e l o f c o ns c i o u s ne s s a t
t h e
t i m e
o f t h e
e l e c t r o c a r d i o g r a m s : g r o u p
1 was
m e n t a l l y
n o r m a l
( 1 0 3 c a s e s ) ,
g r o u p
2
was
d r o w s y
8 5 5
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4/9
HERSCJI
F i g u r e
3
L e f t .
The
T
waves
were
i n v e r t e d
i n t h e
t h r e e
s t a n d a r d
l e a d s ,
a v e r
and
V 2
t o
V 6 .
F o ur
d a y s
l a t e r ,
r i g h t ,
T
waves b e c a m e
u p r i g h t
e x c e p t i n
l e a d
III.
The
S - T ' s
were e l e v a t e d
i n t h e s t a n d a r d an d
pre -
c o r d i a l
l e a d s ,
more
m a t r k e d
i n
t h e
l a t e r
t r a c i n g .
( 1 2
c a s e s ) , group
3
was s t u p o r o u s
( 2 9 c a s e s ) , and
g r o u p
4
was
comatose ( 2 0
c a s e s ) . Eleven
p a t i e n t s
d i e d ,
and
n e c r o p s i e s
were
performed
i n
a l l c a s e s .
R e s u l t s a n d
Comment
T h e
e l e c t r o c a r d i o g r a p h i c f i n d i n g s
were d i -
v i d e d
i n t o
t h e
two
c a t e g o r i e s o f
c h a n g e s
i n
c o m p l e x e s ( t a b l e
1 )
a n d c h a n g e s
i n
rhythm
( t a b l e 2 ) .
T h e
s i g n i f i c a n t
f i n d i n g s may
b e
c l a s s i f i e d
a s
f o l l o w s :
C h a n g e s O c c u r r i n g
More
Commonly
i n t h e
Head
I n j u r y
Group
Than
i n
t h e C o n t r o l
G r o u p s
P
w a v e s
o f i n c r e a s e d
a m p l i t u d e
( f i g .
1 )
w e r e f o u n d
much more c o m m o n l y i n
t h e
p a -
t i e n t s w i t h
h e a d
i n j u r y
t h a n
i n t h o s e
w i t h
l i m b
t r a u m a
( p
=
< 0 . 0 5 ) .
I n
t u r n ,
t h e
i m c i -
d e n c e
o f
t a l l
P w a v e s i n t h e
l a t t e r
g r o u p
w a s
much
h i g h e r
t h a n
t h a t
i n t h e
h e a l t h y
c o n t r o l s
( p
=
< 0 . 0 5 ) .
I n t h e
h e a d
i n j u r y g r o u p t h e t a l l P
w a v e s
w e r e a s s o c i a t e d w i t h
h e a r t
r a t e s a b o v e
9 0
p e r
m i n u t e i n 6 1
p e r c e n t
o f c a s e s
( t a b l e
3 ) .
I t
i s
p o s s i b l e
t h a t
t h e s e P
w a v e s w e r e
d u e t o
s y m p a t h e t i c
s t i m u l a t i o n ,
s i n c e s i m i l a r
P
w a v e s h a v e b e e n n o t e d
d u r i n g e x e r c i s e , 1 7 5
a n x i e t y , ' 6
h y p o x i a , 1 7 a n d
f o l l o w i n g
t h e
a d -
m i n i s t r a t i o n
o f
e p i n e p h r i n e . 5
I n
t h e
r e m a i n -
i n g
c a s e s
t a l l
P
w a v e s
w e r e
f o u n d w i t h
h e a r t
r a t e s
f r o m 5 5 t o 9 0 p e r
m i n u t e , w h i c h
s u g g e s t s
t h a t f a c t o r s o t h e r t h a n
s y m p a t h e t i c s t i m u l a -
t i o n w e r e
o p e r a t i v e .
A n
i n c r e a s e d
Q - T ,
i n t e r v a l w a s
v i r t u a l l y
c o n f i n e d
t o
t h e h e a d
i n j u r y
g r o u p ,
o c c u r r i n g
i n
1 5 p e r c e n t o f t h e c a s e s
( f i g . 2 A ) .
T h e
i n c r e a s e d
Q - T ,
i n t e r v a l ,
l i k e s o m e o f
t h e t a l l
P
w a v e s ,
may b e d u e t o
s y m p a t h e t i c
s t i m u l a t i o n .
I n
man t h e i n j e c t i o n
o f e p i n e p h -
r i n e r e s u l t s i n
a n
i n c r e a s e o f
t h e
Q - T ,
i n t e r v a l . ' 8
Of
t h e
p a t i e n t s w i t h
a n i n c r e a s e d
Q - T , .
i n t e r v a l ,
o n l y 3 6
p e r
c e n t
w e r e a c c o m p a n i e d
b y
h e a r t r a t e s
o f
o v e r 9 0 p e r m i n u t e
a n d
3 2
p e r c e n t a l s o
h a d t a l l P w a v e s .
C h a n g e s
That Appeared
t o
B e
a
N o n s p e c i f i c
R e a c -
t i o n
t o
Trauma
T h e s e
e h a n g e s
o c c u r r e d w i t h
s i m i l a r f r e -
q u e n c y
i n
b o t h
t h e
g r o u p s
w i t h
t r a u m a
( A
a n d
B ) .
At
t h e s a m e t i m e
t h e i n c i d e n c e
o f
t h e
c h a n g e s
i n
t h e s e g r o u p s was g r e a t e r
t h a n
i n
t h e
h e a l t h y c o n t r o l
g r o u p
C .
T h e p v a l u e s
g i v e n
b e l o w
d e s i g n a t e t h e
l e v e l
a t w h i c h t h e
d i f f e r e n c e b e t w e e n
t h e
t r a u m a t i c
g r o u p s
a n d
t h e
h e a l t h y
c o n t r o l s
was s i g n i f i c a n t .
1 .
I n c r e a s e d
QR S
v o l t a g e
i n
t h e
p r e c o r d i a l
l e a d s
( p
=
0 . 0 2 ) .
2 .
R a i s e d
S - T
s e g m e n t s
( f i g .
5 )
i n
p r e -
C i r c u l a t i o n ,
Volume
X X I I I ,
June
1 9 6 1
8 5 6
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5/9
ELECTROCARDIOGRAM IN HEAD
I N JURI ES
F i g u r e
4
A .
V e n t r i c u l a r
e c t o p i c
b e a t s
were
p r e s e n t
( u p p e r )
and
l a t e r
( c e n t e r )
t h e
v e n t r i c u l a r
e c t o p i c
b e a t s
c o n s t i t u t e d
t r i g e m i n a l r h y t h m .
Note
a l s o
t h e
t a l l
P
waves.
B . Shows
s i n u s
a r r h y t h m i a
w i t h a
f i x e d
p a c e m a k e r
and an a t r i a l
e c t o p i c
b e a t .
c o r d i a l
l e a d s
( p
=
0 . 0 1 ) .
I t
i s o f
i n t e r e s t
t h a t
4 8
p e r c e n t o f
t h e
h e a l t h y Bantu
c o n t r o l s
h a d
i n c r e a s e d QR S
v o l t a g e
b y
s t a n d a r d s e s t a b -
l i s h e d f o r
w h i t e s u b j e c t s
( S o k o l o w
and
L y o n 1 9 ) .
A l s o ,
r a i s e d
S - T
s e g m e n t s
were
f o u n d i n
3
p e r
c e n t
o f
s u c h
c o n t r o l s .
B o t h
i n c r e a s e d QR S
v o l t a g e
a n d
r a i s e d S - T seg-
ments
h a v e
p r e v i o u s l y
b e e n
d e s c r i b e d
b y
G r u s i n
i n
n o r m a l
B a n t u . 2 0
3 .
I n v e r t e d
T
waves
i n
p r e c o r d i a l
l e a d s
V ,
T a b l e
4
C h a n g e s
i n I n d i v i d u a l
E l e c t r o c a r d i o g r a p h i c
C o m p o n e n t s
Group
1
Group
2
Group
3
Group
4
1 0 3 C a s e s
1 2
C a s e s 2 9
C a s e s
2 0 C a s e s
Type o f c h a n g e
P
w a v e s 2 . 5 mm.
2 3
( 2 2 . 3 )
3
( 2 5 6 X , )
9
( 3 1 / o )
5
( 2 5 )
o r
more
I n c o m p l e t e
r i g h t
5
(
4 . 8 % T )
0
1
( 3 % S )
1 (
5 % 0 )
b u n d l e - b r a n c h
b l o c k
P r o l o n g e d
Q - T ,
1 6
( 1 5 . 5 )
0
6
( 2 1 )
4
( 2 0 )
S - T
s e g m e n t r a i s e d
more
t h a n
2 . 5 mm.
1 1
( 1 0 . 7 )
3
(25 )
4
( 1 4 % c , )
4
( 2 5 o )
i n V
l e a d s
I n v e r t e d
T
w a v e s
V 4 - 0
7
( 6 . 8 )
2
( 1 7 )
3
( 1
0 r )
4
( 2 0 o )
U
waves t a l l e r t h a n 1 1
( 1 0 . 7 )
1
( 1 7 )
1 0
( 3 4 % / )
1 3
( 6 5 )
mm.
Type
o f
a r r h y t h m i a
S i n u s
A r r h y t h m i a
( a )
f i x e d
p a c e m a k e r
7
(
6 . 8 % c )
3
( 2 5 )
5
( 2 1 )
2
( 1 0 )
( b ) p a c e m a k e r
w a n d e r i n g
3
(
2 . 9 % , )
2
( 1 7 )
3
( 1 0 % l )
4
( 2 0 )
i n
s i n o a t r i a l n o d e
( c ) p a c e m a k e r
w a n d e r i n g
t o
a t r i o v e n t r i c u l a r
1
(
. 9 ' A )
1
(
8 C / . )
1
(
3 % / )
2
( 1 0 C / )
n o d e
2
( 1 7 / 7 )
1 (
3 % o )
4
(20 )
E x t r a s y s t o l e s
2
(
1 . 9 )
Nodal
r h y t h m
1
(
. 9 % , ) 1 (
8 )
0
4 ( 2
0 r )
A t r i o v e n t r i c u l a r
b l o c k
0
0 0
1
(5)
T o t a l
number o f
c h a n g e s
8 7
1 8
4 4
4 8
T o t a l
a v e r a g e number
. 8 4 1 . 5 0
1 . 5 2
2 . 4 0
o f
c h a n g e s p e r
case
C i r c u l a t i o n ,
Volume
X X I I I ,
June
1 9 6 1 i
8 5 7
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6/9
H E R S C H
1
A
a 3
B
752
t
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - ' ' ' - -
- -- - - - - -
52
F ~~~~~~G
1 . ,6MAY58
MA Y
1NOV58
Figure
5
A
shows
u w a d e r i n g
of
the
Pacemaker
in
the
sinoatrial
node. In
B
the
pacemtaker
wanders
to
the
atrioventricular
node.
A
V a l s a l v a
maneuver
(x)
results
in
sinus
r - h y t h m n
( C ) .
After
the
Valsalva
m a n e u v e r . ,
D
shows
wandering
o
f
t h ~ e
pacemaker
to the
atrioventricular
node and
E
shows
nodal
rhythm.
Four
days
later,
F
and G show
wandering
o f
the
pacemaker
in
the
atrio:entricular
node. Sinus
rhythm
i s restored
3
days
later
(H
and
i).
5;Bz
t +w
^-- +
+ *
t
:
...
. ft t
j ~ t .
.;
t^
.,i
Y:ws
:
_ ~ . o ,
< : t
m
: e > e s e < < e
: . . s : . .
> - F F :