# Paced Rhythm/12 Lead?



## terrible one (Jun 10, 2010)

Possibly a dumb question so forgive my ignorance, but do you perform a 12 lead on symptomatic pt that has an internal pacer? If so how do you interpret the 12 lead for a STEMI?
Thanks


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## MSDeltaFlt (Jun 10, 2010)

terrible one said:


> Possibly a dumb question so forgive my ignorance, but do you perform a 12 lead on symptomatic pt that has an internal pacer? If so how do you interpret the 12 lead for a STEMI?
> Thanks


 
You should do a 12 Lead to make sure it is a paced rhythm.  If you see the spikes, then that will be about it.  Treat symptomatically and transport.  Those pts might be getting a diagnostic cath once in the hospital or at least serial enzymes/ECG's for more accurate assessment.


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## terrible one (Jun 11, 2010)

Don't most pacer spikes show up on a 3 lead though? Do you have to confirm it with a 12 lead?


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## TomB (Jun 11, 2010)

You absolutely perform a 12-lead ECG! 

You can use the same rules for diagnosing acute STEMI with paced rhythm that you use for diagnosing STEMI in the presence of LBBB. This is referred to as "Sgarbossa's criteria" and it came from the GUSTO investigators.

1.) ST-elevation > 1 mm that is concordant (in the same direction as) the QRS complex
2.) ST-depression > 1 mm in the right precordial leads (V1-V3)
3.) ST-elevation > 0.2 the depth of the S-wave for QRS complexes that are negative (discordant ST-elevation).

The third criterion is a modified form of Sgarbossa's original criteria.

As for the pacemaker spikes, often they are visible as "blips" in leads V3-V5 but you can often recognize paced rhythms based on QRS morphology if you can't see the spikes.

Remember to expose the chest of every chest pain patient and look for a pacemaker/ICD can in the upper right or upper left chest as well as a surgical scar indicating prior heart surgery.

One final thought, even if you don't remember Sgarbossa's criteria, you can still identify coronary ischemia by comparing serial ECGs with LBBB and paced rhythm.

Tom


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## Aidey (Jun 11, 2010)

Do not assume you will be able to see the pacer spikes, or that your monitor will pick up 100% of them. I've been noticing that some of the newer pacemakers are...subtle for lack of a better term.


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## rhan101277 (Jun 11, 2010)

Aidey said:


> Do not assume you will be able to see the pacer spikes, or that your monitor will pick up 100% of them. I've been noticing that some of the newer pacemakers are...subtle for lack of a better term.



Yeah our instructor told us about the spikes not being as visible on newer models.  I haven't seen this real world yet.


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## Aidey (Jun 11, 2010)

Just guessing I would say about 1/4 to 1/3 of the pacemakers I run into are new enough they aren't obvious on the EKG. I've started making a habit of asking the pt how old their pacemaker is so I know what to expect.


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## 360joules (Jul 7, 2010)

I always do one... it's easier to just slap on the 12 lead cables and run one (even though you typically know what it's going to be... a pacer rhythm)  than to sit in front of QA/QI under the interrogation lamp and explain why you didn't do one for the general weakness patient.  Then follow MSDeltaflt's advice and treat symptomatically and transport.


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## WolfmanHarris (Jul 7, 2010)

I'd do one, but paced rhythm is a contraindication for STEMI bypass in my system. So the serial 12 leads would just be for record-keeping and continuum or care.


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