# Bigeminy or paced rhythm?



## Mohrenberg (May 8, 2012)

I am finishing up clinicals for paramedic school, and went on a chest pain last night with a Medic based out of the ED.
The call was toned as an 82 year old male complaining of chest pain. 
He said his pain start 3 hours prior and he had thought it was indigestion, when unable to fall asleep, he called 911.
Described the pain as sharp, radiating to his jaw rating it a 7/10.
Patient had a hx of MI in 1995, 6x cardiac stents, pacer on his left side, copd, ect..

Anyways, while enroute he kept throwing wide complex qrs's on the monitor, the medic said it was his pacer but I never saw any pacer spikes. They would be random, and then every once in a while he would go into a bigeminy rhythm.

at one point, I looked over at the monitor and saw what looked like Vtach at 115bpm on the monitor.. I looked over at the patient who was still AO, asked, "How are you feeling?" he replied he felt fine, so i checked his radial which was present. I tapped the medic on the shoulder who was doing something in the cabinets, and she said it was his pacer.
I didn't know that pacers fire at 115bpm?
Then the patient said his chest was starting to "burn" like he was "being pushed through a small hole" (that's a new one for me)

His rhythm then converted back.

So i'm trying to find out, were these really paced beats, or was this guy in bigeminy with runs of vtach?
Unfortunately I don't have a strip of the vtach, but I've got a strip of the bigeminy.


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## bstogner (May 8, 2012)

I am still pretty new to EKG interpretation but, I would call that bigeminy.  And in that case assume that he was likely having runs of V tach too.


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## jwk (May 8, 2012)

I'd vote intermittent bigeminy.  There's no V-Tach, at least on this strip.

Pacers definitely aren't set at 115 - and you're right - there are no pacer spikes or anything closely resembling them.


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## MedicBender (May 8, 2012)

I would call that bigeminy as well. 

Was the monitor showing arrows at the bottom of the strip during these runs of vtach? 

The LP12 should identify it as a pacer and label the paced beats with a small arrow at the bottom.


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## Aprz (May 8, 2012)

Did you do a 12-lead?


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## Milla3P (May 9, 2012)

With the strip... It appears bigeminal, but it appears to desolate before the end of the strip. We're the PVC's conductive? What was the B/P? PMHX?

The fun part of LP12s is that they only recognize Physio pacemakers. I've seen pacing spikes on Zolls and not my LP with the same guy. 
Most of the time you can get a pretty good Hx from a pt about their pacemaker if you're good at translating the foreign language of "old guy"


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## Milla3P (May 9, 2012)

Also where's your 12-lead?


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## Aidey (May 9, 2012)

Just for the record, some of the newer pacemakers have very very subtle pacer spikes and the monitors won't always pick them up and put the little pacer arrow at the bottom. Sometimes if there is any artifact at all it can obscure the pacer spikes.


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## Christopher (May 9, 2012)

MedicBender said:


> The LP12 should identify it as a pacer and label the paced beats with a small arrow at the bottom.



The LP12 is pretty horrible at detecting newer paced rhythms and frequently believes artifact to be pacer spikes. Also you can accidentally turn it off, or like my service, have it off by default.


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## Christopher (May 9, 2012)

Mohrenberg said:


> So i'm trying to find out, were these really paced beats, or was this guy in bigeminy with runs of vtach?
> Unfortunately I don't have a strip of the vtach, but I've got a strip of the bigeminy.



Looks like a sinus rhythm with 1st degree AVB, bigeminal PVCs, and some fusion beats towards the right side of the strip when the PVCs take a bit longer to fire.






This potentially means the patient has an ectopic ventricular focus that is firing at a fixed rate, slightly out of sync with the sinus rate. Neat strip either way.

As for pacemakers at 115 bpm, sure, if it is a demand pacemaker that senses the atria and the patient is experiencing sinus tachycardia.


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## Mohrenberg (May 9, 2012)

Milla3P said:


> Also where's your 12-lead?



Medic did a 12 & 15 lead, I don't have those strips though. Doc in a box called it first degree block with pvc's when he wasn't in this bigeminy rhythm.

It was an hour and fifteen minute transport to kansas city, his pain never returned after the first nitro, aside from the "burning" during the run of vtach, which went away when he converted back into his first degree block.


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## Milla3P (May 9, 2012)

Sometimes a paced rhythm doesn't look textbook with a little spike and a neat little complex. Sometimes it looks all wide and crazy but generally uniform. If the pt was in a 1st degree it could of been a demand pacer and only pace some of the time and that could of looked like VTach, or he could of been going into runs and that's why he has the pacer to begin with.


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## EMSpursuit (May 10, 2012)

*Bigeminy*

Looks to be Bigeminy....


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## jroyster06 (May 10, 2012)

I would call it bigeminy just for the fact that they are so differnt in shape. usually the pacer beats will be much more simular on the print out.


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## Handsome Robb (May 10, 2012)

Sinus rhythm with 1st degree block and bigeminy.


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## ZootownMedic (May 13, 2012)

Agree with the Bigeminy and 1st Degree AVB. Congrats on getting close to the end of Medic school. I graduated last week


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## EnviroMed (May 25, 2012)

could be accelerated IVR after reperfusion with residual ischemic producing PVCs. :unsure:


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