ECG of the Week - 17th April 2017 - Interpretation

This ECG is from a 79yr old male who presented to the Emergency Department with central abdominal pain secondary to an incarcerated hernia. A pre-op ECG was performed and is below.

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Rate:

• 66 bpm

Rhythm:

• Regular
• Ventricular paced rhythm
• Pacing spikes best seen in lead V2
• Evidence of possible native atrial activity

Axis:

• Normal

Intervals:

• QRS - Prolonged (160ms)

Segments / Additional:

• Typical LBBB morphology
• Discordant ST / T wave changes
• Magnitude of ST change is appropriate for QRS voltages 

Interpretation:

• Ventricular paced rhythm
• Nil features to suggest pacemaker problem
• 100% Capture
• Nil evidence of sensing failure
• Sgarbossa / Modified Sgarbossa negative

The pre-operative assessment of a the patient with an implantable device is outside the scope of Emergency Medicine practice but the following articles have a good overview of how to approach the peri-operative management of patient's with pacemakers:

• Salukhe TV, Dob D Sutton R. Pacemakers and defibrillators: anaesthetic implications. Br J Anaesth 2004; 93 (1): 95-104 [FULL TEXT]
• Crossley GH, Poole JE, Rozner MA, Asirvatham SJ, Cheng A, Chung MK, Ferguson TB Jr, Gallagher JD, Gold MR, Hoyt RH, Irefin S, Kusumoto FM, Moorman LP, Thompson A.. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management. Heart Rhythm. 2011 Jul;8(7):1114-54.
• Stone ME, Salter B, Fischer A.Perioperative management of patients with cardiac implantable electronic devices.Br J Anaesth. 2011 Dec;107 Suppl 1:i16-26.

  

References / Further Reading

Life in the Fast Lane

• Normal Pacemaker Function
• Pacemaker Malfunctions
• Sgarbossa Criteria

Textbook

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