ECG of the Week - 20th May 2013 - Interpretation

This ECG is from a 64 year old male. 
Presented following multiple episodes of syncope.

Click to enlarge

Rate:

• ~42 bpm mean ventricular rate

Rhythm:

• Irregular
• Junctional escape rhythm 
• Complexes number 1, 3, 4, 5
• Rate ~ 36 bpm
• Sinus 
• Complexes number 2, 6, 7

Axis:

• Normal (~70 deg)

Intervals:

• PR - Upper limit normal where present (~200ms)
• QRS - Normal (100ms)
• QT - 520ms

Segments:

• ST Sagging leads II,III,aVF,V5-6

Additional:

• T wave notching in leads V1-3 in 5th complex likely secondary to lead transition
• Biphasic T wave V1
• P waves broad & notched

Interpretation:

• Intermittent sinus arrest with junctional escape rhythm

What happened ?

This ECG was captured during a symptomatic episode of presyncope. 
The patient then spontaneously reverted to sinus rhythm after a few minutes.
His beta-blocker was ceased and he was transferred for PPM insertion.

VAQ Corner

A 64 year old male presents to your ED following an episode of syncope.
He complains of feeling lighted. 
BP 105/60 RR 18 Sats 96% Room Air

a) Describe & interpret his ECG (50%)
b) Outline your management (50%)

References / Further Reading

Life in the Fast Lane

• Sinoatrial exit block here
• Sick Sinus Syndrome here

Textbook

• Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.