The following ECG is from a 74yr old male who presented following several episodes of chest pain and dizziness.
Click to enlarge |
- 66 bpm
- Nil p waves
- Fibrillation waves best seen leads V1 & V3
- Regular ventricular rhythm
- Each ventricular complex associated with a pacing spike
- Best seen leads II, aVR, aVF, V1, V3-6
- Left
- Superiorly at ~ -70 degrees
- QRS - Prolonged (200ms)
- Appropriate discordant T wave and ST changes
- No evidence of excessive discordance
- Note QRS relatively low voltage in leads V1-2
- Need to check ECG lead placement
- Compare with old ECGs
- Monitor for dynamic change
- Ventricular paced rhythm
- All complexes paced
- Absence of native rhythm
- Lead placement likely right ventricular apex
- Nil atrial activity seen
Quick pacemaker points
Remember a few things about patients with pacemakers.
Pacemaker activity visualised on the 12-lead is dependent on several factors:
- Pacemaker programming
- Patient's current native rhythm
- Wire placement
- Appropriate wire position and function
- Patient's other activity co-morbidities - drug toxicity, ACS, electrolyte abnormality etc.
What might you see:
- No pacing activity / Native rhythm only
- Atrial pacing only
- Ventricular pacing only
- Combination of atrial and ventricular pacing
- Combination of all the above
Life in the Fast Lane
Textbook
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
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