# Wide Complex EKG



## Sublime (Aug 12, 2014)

These EKGs belong to a 74 year old female being transferred from a small hospital to a large facility for orthopedic services due to a L2 compression fracture that happened a few days prior. She came to the ER days later due to worsening back pain. Her only complaints are feeling "dizzy" which occurred post dilaudid administration by the ER staff and severe back pain. Her labs were all within normal limits. 

ER nurse reports she has been in a-fib with RVR for which she was given Lopressor to no effect. 

Patient Hx: A-Fib, pacemaker, cardiac ablation, hypertension, and high cholesterol. The type of pacemaker is unknown, the patient does state that it is not a defibrillator but only a pacemaker.

Initially she is in sinus tachycardia when I place her on the monitor. A short time into the transport she suddenly develops a wide-complex tachycardia. I interpreted it as a paced rhythm. She converts back into sinus tachycardia and into this rhythm multiple times during transport. At one point the rhythm was sustained for a couple minutes.

I considered giving amiodarone as the rate would at a couple points climb to 140-150 for a couple seconds before slowing down to around 120.

Due to the fact the patient was alert, denied any complaints but back pain, and was self-converting back into a sinus rhythm I decided to just keep monitoring her. Captured a somewhat poor 12-lead during one episode. Was on a rather bumpy highway.

I am assuming this is pacemaker malfunction, what do you guys think? Any other thoughts?


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## atropine (Aug 12, 2014)

Looks like 100% paced rhythm for a while and then artifact, if she looked good with no type of cardiovascular or respiratory complaint you are gold.


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## chaz90 (Aug 12, 2014)

Hmm. Is the wide complex rate identical to the narrow complex sinus tach? I can't see it well on my phone, but it doesn't look like the rate changes.


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## teedubbyaw (Aug 12, 2014)

Demand pacer? We know pacing can cause wide complexes, so I wouldn't be overly concerned unless she become symptomatic. Can't see on phone.


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## zzyzx (Aug 14, 2014)

I don't see any pacer spikes on the 12-lead. A pacemaker malfunction is very unusual anyhow.


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## d_miracle36 (Aug 14, 2014)

How can you tell it is a paced rhythm? I see no pacer spikes. The patient has a wide complex tachycardia with negative concordance in all of the precordials and a positive QRS in avl. This appears to be vtach in my opinion.


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## atropine (Aug 14, 2014)

d_miracle36 said:


> How can you tell it is a paced rhythm? I see no pacer spikes. The patient has a wide complex tachycardia with negative concordance in all of the precordials and a positive QRS in avl. This appears to be vtach in my opinion.


You're right bad pic on my phone.


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## Sublime (Aug 15, 2014)

teedubbyaw said:


> Demand pacer? We know pacing can cause wide complexes, so I wouldn't be overly concerned unless she become symptomatic. Can't see on phone.


 A demand pacemaker will begin pacing when it is not sensing a sufficient electrical stimulus. I don't see any evidence on these strips that this is occurring because of a demand problem. But it could be failure of the pacemaker to sense. Not sure



d_miracle36 said:


> How can you tell it is a paced rhythm? I see no pacer spikes. The patient has a wide complex tachycardia with negative concordance in all of the precordials and a positive QRS in avl. This appears to be vtach in my opinion.



Not unheard of for a Zoll to not pick up pacer spikes. Has occurred multiple times in my practice. Also the rate of 120 leads me away from V-Tach.


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## Handsome Robb (Aug 15, 2014)

Seems like a pacer malfunction. I had a patient with a malfunctioning AICD who'd get zapped, paced, not paced when he needed it, ect. Wonky looking rhythm strips.

That's my bet.


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## Sublime (Aug 15, 2014)

d_miracle36 said:


> The patient has a wide complex tachycardia with negative concordance in all of the precordials and a positive QRS in avl. This appears to be vtach in my opinion.





atropine said:


> You're right bad pic on my phone.



Also, while what you're describing is correct, it is a pretty standard appearance for a ventricular pacer with a RV pacing wire and does not point toward v-tach.


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## d_miracle36 (Aug 15, 2014)

Sublime said:


> Also, while what you're describing is correct, it is a pretty standard appearance for a ventricular pacer with a RV pacing wire and does not point toward v-tach.


I agree with everything you have said and considered it before posting. I should have been more thorough. I agree that a rate of 120 is low for vtach but its not unheard of. Although the pacer may be causing this, right now theres no way to know, is there? Do you have a follow up, or were you able to get an old ECG of the patient while pacing exhibiting the same morphology? I agree with your treatment and don't exclude the possibility of it being a pacemaker malfunction.


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## jrm818 (Aug 16, 2014)

Certainly not ruling out a paced rhythm, but a pacer that is simply not sensing still wouldn't pace at 120 and definitely shouldn't vary it's rate from 120-150 and back.  It could be a very strange combination of malfunctions, but that sounds like a bit of a stretch.

It's a bit tough with the road-quality ekg, but I see what almost looks like a fusion beat at the beginning of each wide-complex period.  Not a fusion per-se, but the morphologies look like they change gradually over 1-2 beats into the wide complex beats.  I wouldn't expect that from a pacer taking over, though I suppose it's possible.  I think chaz is right that the rate is almost exactly the same after the switch to wide, which is sort of weird.  I wonder if this is intermittent SVT (or even sinus tach with buried p waves) with aberrant conduction?  slow vtach certainly possible.  I doubt can know for sure what it was without interrogating the pacer or an EP study.


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## Christopher (Aug 18, 2014)

Sublime said:


> These EKGs belong to a 74 year old female being transferred from a small hospital to a large facility for orthopedic services due to a L2 compression fracture that happened a few days prior. She came to the ER days later due to worsening back pain. Her only complaints are feeling "dizzy" which occurred post dilaudid administration by the ER staff and severe back pain. Her labs were all within normal limits.
> 
> ER nurse reports she has been in a-fib with RVR for which she was given Lopressor to no effect.
> 
> ...



What is this, an ECG for ants?!?! (just kidding, but only sort of)

From the 10 mile view, it could be:

1. Slow VT
2. PMT
3. PAF w/ wide complexes
4. Atrial tracking by the pacemaker

The onset begins with a PVC, which may be of interest.


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## Sublime (Aug 18, 2014)

Christopher said:


> What is this, an ECG for ants?!?! (just kidding, but only sort of)
> 
> From the 10 mile view, it could be:
> 
> ...


Can you not click on them to open the pictures in a gallery for a much larger view?


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## Christopher (Aug 19, 2014)

Sublime said:


> Can you not click on them to open the pictures in a gallery for a much larger view?



Not much larger, nope.


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## Jason (Aug 21, 2014)

1) A-Fib with RVR.
2) Slow VT. 
3) Not Pacemaker induced.


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## jcroteau (Aug 29, 2014)

Hey everyone, new medic student here.....I'm having trouble posting my own topic in this forum.....so I thought this may be the most appropriate thread to ask my question. 

Can someone please tell me why wide qrs complexes are bad? Does it have something to do with r on t?

I've asked numerous medics and the only answer I keep getting is "it just is"


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## teedubbyaw (Aug 30, 2014)

jcroteau said:


> Hey everyone, new medic student here.....I'm having trouble posting my own topic in this forum.....so I thought this may be the most appropriate thread to ask my question.
> 
> Can someone please tell me why wide qrs complexes are bad? Does it have something to do with r on t?
> 
> I've asked numerous medics and the only answer I keep getting is "it just is"



There's a lot of reasons, and different wide morphologies that mean different things. Essentially, it usually means slow cell to cell conduction/problem with the pathways, and can effect hemodynamics or progress into a lethal rhythm.


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## jcroteau (Aug 30, 2014)

Excellent! Thanks for the reply!


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## Handsome Robb (Aug 30, 2014)

jrm818 said:


> Certainly not ruling out a paced rhythm, but a pacer that is simply not sensing still wouldn't pace at 120 and definitely shouldn't vary it's rate from 120-150 and back.  It could be a very strange combination of malfunctions, but that sounds like a bit of a stretch.
> 
> It's a bit tough with the road-quality ekg, but I see what almost looks like a fusion beat at the beginning of each wide-complex period.  Not a fusion per-se, but the morphologies look like they change gradually over 1-2 beats into the wide complex beats.  I wouldn't expect that from a pacer taking over, though I suppose it's possible.  I think chaz is right that the rate is almost exactly the same after the switch to wide, which is sort of weird.  I wonder if this is intermittent SVT (or even sinus tach with buried p waves) with aberrant conduction?  slow vtach certainly possible.  I doubt can know for sure what it was without interrogating the pacer or an EP study.



Definitely agree with this.

It's anecdotal so n=1 but the PT I had with a pacer malfunction was varying from the 80s-170s ranging from wide to narrow complex with intermittent and changing amplitude if pacer spikes. One of the weirdest things I've ever seen in my short career. He was also "shocked" three times in the shower which what was prompted the 911 call.


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## Jason (Aug 30, 2014)

jcroteau said:


> Hey everyone, new medic student here.....I'm having trouble posting my own topic in this forum.....so I thought this may be the most appropriate thread to ask my question.
> 
> Can someone please tell me why wide qrs complexes are bad? Does it have something to do with r on t?
> 
> I've asked numerous medics and the only answer I keep getting is "it just is"


Hello. Many rhythm questions (as you are a medic student), aren't always a straight forward answer .... Unfortunately.  
I work in a Cath Lab and cross trained for EP Lab. If you would like help with rhythms and 12 Leads and general cardiology,  I'd be happy to help. However answers may be more suitable for private threads or email.


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## Jason (Aug 30, 2014)

jcroteau said:


> Hey everyone, new medic student here.....I'm having trouble posting my own topic in this forum.....so I thought this may be the most appropriate thread to ask my question.
> 
> Can someone please tell me why wide qrs complexes are bad? Does it have something to do with r on t?
> 
> I've asked numerous medics and the only answer I keep getting is "it just is"


R on T is a separate issue from Wide Complex QRS.  R on T can happen with many rhythms, but more involved with QT intervals and premature beats.
And as for "it just is" - is not the answer medics should give to those learning.  We should be striving for better care ... and helping each other.  Wide QRS is the norm for some people.  So for those ... its not that bad.  Wide QRS can be a morphology change, like changes in rhythm that aren't necessarily life threatening .. kinda like A-Fib.  A-Fib is not good, but people live with it.  On the other hand, Wide QRS can also be bad.  Acute changes resulting in potential lethal rhythm changes.  Electrophysiology can be very complex.  Looking at the morphology of the heartbeat, the P-wave, the QRS complex, and the T-wave, can tell you a lot about the heart.


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## jcroteau (Aug 30, 2014)

I guess my question would turn into why do we treat it with sodium bicarb....what would happen if we just left it as is? The potential to deteriorate into more lethal rhythms?


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## DesertMedic66 (Aug 30, 2014)

jcroteau said:


> I guess my question would turn into why do we treat it with sodium bicarb....what would happen if we just left it as is? The potential to deteriorate into more lethal rhythms?


Treat what with sodium?


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## jcroteau (Aug 30, 2014)

Wide complex QRS......anything over 0.12 seconds we're giving bicarb.


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## Handsome Robb (Aug 30, 2014)

jcroteau said:


> Wide complex QRS......anything over 0.12 seconds we're giving bicarb.



I'd love to hear the reasoning behind this.

I 100% agree with basically everything you said until this post.


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## jcroteau (Aug 30, 2014)

Sorry sorry sorry. I totally could have worded that better......any of the following with a wide QRS we are giving bicarb;

CCB or BB Overdose, Sympathomimetic OD or TCA OD

So I guess I'm asking if we have a wide QRS complex secondary to any of the above why are we treating it and what could happen if we didn't.


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## teedubbyaw (Aug 30, 2014)

Bicarb is used in TCA overdose, but can't say I've heard of it being used in the others.

Bicarb is fairly standard in cardiac arrest, including pulseless Vtach, but that's to treat acidosis. 

Not sure what or where exactly your information is coming from. Seems a little off.


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## STXmedic (Aug 30, 2014)

jcroteau said:


> of the following with a wide QRS we are giving bicarb;
> 
> CCB or BB Overdose, Sympathomimetic OD or TCA OD


Hmm...


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## Handsome Robb (Aug 31, 2014)

jcroteau said:


> Sorry sorry sorry. I totally could have worded that better......any of the following with a wide QRS we are giving bicarb;
> 
> CCB or BB Overdose, Sympathomimetic OD or TCA OD
> 
> So I guess I'm asking if we have a wide QRS complex secondary to any of the above why are we treating it and what could happen if we didn't.



As far as I know bicarb is not indicated in CCB or BB OD. In the acute phase at least.

TCA OD absolutely, the question is do you know why outside of "the protocol says so"?


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## Handsome Robb (Aug 31, 2014)

I stand corrected.

http://emcrit.org/wp-content/uploads/ccb.pdf

With that said I'm not super keen on messing with people's blood chemistry unless I absolutely have to. We don't give bicarb for CCB or BB ODs, only TCAs on standing orders of 1mEq/kg once. 

Gone untreated it will result in a cardiac arrest but like I said unless they're severely symptomatic, read: peri-arrest or prolonged seizure activity refractory to benzodiazepines, I'm not going to **** with someone's pH.


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## TheLocalMedic (Aug 31, 2014)

I've been doing this for a while, and it's been years since I've seen a pacemaker have problems, so I'm not inclined to think that this is her pacer (nor do I see any pacing spikes or indicators from the monitor that it is detecting a pacemaker).  I don't think it's an aberrant conduction either, because usually that occurs at a higher rate.  

I'm sticking with v-tach on this one.   While I'm not a huge fan of Amiodarone, I would probably hang it in this case because those are some pretty sustained runs of v-tach.


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## tpchristifulli (Sep 8, 2014)

With the Zolls I have to drop the age to like 3 years old to get the pacer spikes to show up on the 12 lead. Sounds like a dual chamber pacer. No need for intervention. Remember if your not sure if it's a paced tach or ventricular tach you can always wave a pace magnet and drop the hr back to programmed rate.


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