Wide Complex EKG

[Sublime]

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?

 

[atropine]

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.

 

[chaz90]

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.

 

[teedubbyaw]

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.

 

[zzyzx]

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

 

[d_miracle36]

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.

 

[atropine]

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.

 

[Sublime]

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

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.

 

[Handsome Robb]

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.

 

[Sublime]

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.

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.

 

[d_miracle36]

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.

 

[jrm818]

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.

 

[Christopher]

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?

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.

 

[Sublime]

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.

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

 

[Christopher]

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

Not much larger, nope.

 

[Jason]

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

 

[jcroteau]

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"

 

[teedubbyaw]

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.

 

[jcroteau]

Excellent! Thanks for the reply!

 

[Handsome Robb]

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.