EKG case

[ERMudPhud]

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What is the rhythm and how do you treat it. Let the med students or interns try first before everyone jumps in

Since the grid lines didn't scan well I will tell you the heart rate is 150

 

[Hayduke]

Is this someone's pacemaker gone horribly wrong causing 'pacemaker mediated tachycardia'?

If it is and the pt is symptomatic, then tx. by:
1.placing a magnet over the device while continuous monitoring w/a transdermal setup ready to go
2.call for calibration tech

 

[hyperbaric]

Is this someone's pacemaker gone horribly wrong causing 'pacemaker mediated tachycardia'?

Looks like a pacer spike to me, but the image is diificult to see. If so, I agree with Hayduke.

 

[hyperbaric]

Looks like a pacer spike to me, but the image is diificult to see. If so, I agree with Hayduke.

For treatment, call Medtronics cause I don't know.

 

[LotaPower]

ok stupid question...I never really understood this magnet and interrogation thing... can you change the rate or what?

Is this someone's pacemaker gone horribly wrong causing 'pacemaker mediated tachycardia'?

If it is and the pt is symptomatic, then tx. by:
1.placing a magnet over the device while continuous monitoring w/a transdermal setup ready to go
2.call for calibration tech

 

[Hayduke]

"Placing a magnet over a permanent pacemaker causes sensing to be inhibited by closing an internal reed switch. This only temporarily "reprograms" the pacer into the asynchronous mode, where pacing is initiated at a set rate. It does not turn the pacemaker off. Each pacemaker type has a unique asynchronous rate for beginning-of-life (BOL), elective replacement indicator (ERI), and end-of-life (EOL). Therefore, application of a magnet can determine if the pacer's battery needs to be replaced. Further interrogation, or manipulating of the device, should be performed by an individual skilled in the technique. Patients should carry a card that contains information about their particular pacemaker, since these rates are dependent on the manufacturer and the model."

This is a nice synopsis obtained by a shameless cut and paste from
http://www.emedicine.com/emerg/topic805.htm

 

[Derek]

I agree it looks like a runaway pacemaker. If magnet does not work then externalize the pacemaker and cut the wires and get ready to do some external pacing.

 

[JaySin]

For me i just drive faster.

 

[TPS report]

uhhh....is that an EEG tracing...?

 

[lucky_deadman]

I can't get a good look at the 12 lead, but appears like it could be refractory V Tach. Could be some AVRT with aberrancy. Either way if patient is symptomatic, I looking to probably cardiovert.

 

[stoic]

no actue changes... that's just dick cheney's baseline EKG!

j/k

i'm gonna have to agree with everyone else here and say that looks like a pacemaker gone bad. it's interesting, in the avF lead it certainly looks like there's a regular P-wave just barely poking through that monster of a QRS. so does that mean we've got a dual lead unit here?

so the long term treatment would be to reprogram/replace the pacemaker. call the patients cardiologist.

in the ED, the course of action would probably be decided by a number of things. pt history is vitally important here... if this is the heart of an 85yo with a hx of MI & CABG and is currently symptomatic, then its got to be slowed down ASAP or ischemic changes will be added to this list of things wrong with this EKG. setup the patient to pace externally, then attempt to either shut down or reset the pacemaker using the external magnet. if the patient was succesfully converted to normal rhythm, i'd still be watching them closely and probably want to admit. i'd be worried about hemodynamic stability in a patient with cardiac history where we've just cut the cardiac output in half (hr from ~150 to 80).

i dunno, those are my musings.

 

[ERMudPhud]

This is what is called pacemaker tachycardia. Its not so much a case of the pacemaker having gone bad as it is just being confused. It typically occurs with a DDD pacemaker when the patient has a PVC at just the right time to create a retrograde P wave. The atrial sensor sees the P wave and the pacemaker waits the required time for a ventricular depolarization to occur. When the ventricle fails to depolarize because the AV node just got done conducting the retrograde signal and is refractory the pacemaker steps in and paces the ventricle like it has been programmed to do. By the time that signal gets to the AV node it is no longer refractory and another retrograde P wave gets conducted thus starting the whole cycle over again. Its like a re-entrant tachycardia via the pacemaker. Those are retrograde P waves you see in AVF. There are a variety of other mechanism by which the tachycardia can be triggered but this is the easiest one for me to remember and understand

If you place a magnet even for a second it forces the pacemaker to pace at a set rate, ignoring the retrograde P wave, and breaks the cycle. The pacemaker is then usually programmed to lengthen the time after a QRS before it starts looking for a P wave so that it doesn't happen again. Theoretically, if the retrograde conduction is going via the AV node you could also break the cycle with adenosine but you shouldn't need to. Next time you are in the ED ask where the pacemaker magnet is kept.

I wouldn't start digging the pacemaker out of their chest until you've tried everything else.

I'll post the magnet induced EKG later when I have a chance.

 

[Hard24Get]

Thank you! 😍 The faculty at SDN EM are great about teaching! 😉

This is what is called pacemaker tachycardia. Its not so much a case of the pacemaker having gone bad as it is just being confused. It typically occurs with a DDD pacemaker when the patient has a PVC at just the right time to create a retrograde P wave. The atrial sensor sees the P wave and the pacemaker waits the required time for a ventricular depolarization to occur. When the ventricle fails to depolarize because the AV node just got done conducting the retrograde signal and is refractory the pacemaker steps in and paces the ventricle like it has been programmed to do. By the time that signal gets to the AV node it is no longer refractory and another retrograde P wave gets conducted thus starting the whole cycle over again. Its like a re-entrant tachycardia via the pacemaker. Those are retrograde P waves you see in AVF. There are a variety of other mechanism by which the tachycardia can be triggered but this is the easiest one for me to remember and understand

If you place a magnet even for a second it forces the pacemaker to pace at a set rate, ignoring the retrograde P wave, and breaks the cycle. The pacemaker is then usually programmed to lengthen the time after a QRS before it starts looking for a P wave so that it doesn't happen again. Theoretically, if the retrograde conduction is going via the AV node you could also break the cycle with adenosine but you shouldn't need to. Next time you are in the ED ask where the pacemaker magnet is kept.

I wouldn't start digging the pacemaker out of their chest until you've tried everything else.

I'll post the magnet induced EKG later when I have a chance.

 

[WilcoWorld]

If only every EKG came with the most informative lead's tracing highlighted & blown up...

Good stuff though, thanks.

 

[leviathan]

uhhh....is that an EEG tracing...?

Sometimes I think there are people in this world who could use a cortical pacemaker...😉

 

[waterski232002]

ERMudPhud... Thanks for the excellent case.

Do all pacers/ICD's respond the same to magnitization? I recall using a magnet to completely disable a pacer/ICD in a patient we declared clinically dead by holding the magnet over the chest for 15 minutes. Is there a difference based on the model or based on the duration you hold the magnet to the patient's chest?

 

[Apollyon]

ERMudPhud... Thanks for the excellent case.

Do all pacers/ICD's respond the same to magnitization? I recall using a magnet to completely disable a pacer/ICD in a patient we declared clinically dead by holding the magnet over the chest for 15 minutes. Is there a difference based on the model or based on the duration you hold the magnet to the patient's chest?

I had a paced patient in June where the magnet - no matter how oriented, right over the pacer - would not do anything. I could NOT get an underlying EKG no matter what I did.

I don't know the model.

 

[ERMudPhud]

According to this link pacemakers can respond in a variety of ways to placement of a magnet

www.anesthesia.wisc.edu/Clinic/ providerinfo/CVrisk/MgmtPACERS2copy.pdf

According to Medtronic's and Guidant's web sites magnets should set all of their pacers to run at a fixed rate until the magnet is removed. It will TURN OFF defibrillator function so if you had a patient in refractory vFIB who you have pronounced I guess you might put on a magnet so they stop being shocked but it shouldn't turn of the pacing function,

 

[JackBauERfan]

ERMudPhud... Thanks for the excellent case.

Do all pacers/ICD's respond the same to magnitization? I recall using a magnet to completely disable a pacer/ICD in a patient we declared clinically dead by holding the magnet over the chest for 15 minutes. Is there a difference based on the model or based on the duration you hold the magnet to the patient's chest?

most of the places i've read it should be only 30 seconds to a minute...reminds me next time we call the medtronix folks I need to ask about that. anyone else know?

 

[mikecwru]

ERMudPhud... Thanks for the excellent case.

Do all pacers/ICD's respond the same to magnitization? I recall using a magnet to completely disable a pacer/ICD in a patient we declared clinically dead by holding the magnet over the chest for 15 minutes. Is there a difference based on the model or based on the duration you hold the magnet to the patient's chest?

I think the standard for AICDs is off, and for pacing it sets it to a predetermined rate, ie, you'll still ventricularly pace the heart muscle on a dead person until the heart muscle dies off.

mike

 

[Apollyon]

I think the standard for AICDs is off, and for pacing it sets it to a predetermined rate, ie, you'll still ventricularly pace the heart muscle on a dead person until the heart muscle dies off.

mike

It'll pace dead heart tissue, too - the old paramedic standby for the DOA - "asystole with pacer spikes".

You know what they do with PPM's in patients who die? Recycle them into dogs and cats.

 

[JackBauERfan]

It'll pace dead heart tissue, too - the old paramedic standby for the DOA - "asystole with pacer spikes".

You know what they do with PPM's in patients who die? Recycle them into dogs and cats.

which brings up the question what happens when the dogs and cats die?

 

[Apollyon]

which brings up the question what happens when the dogs and cats die?

The key is how the corpse is disposed of. PPM's can't go in the crematory because they can blow up.

 

[stoic]

I'll post the magnet induced EKG later when I have a chance.

Cool case, MudPhud! When you've got a chance, can you post the pt's history, ED course, and disposition? Did you have any trouble converting them to a normal rhythym?

 

[ERMudPhud]

Cool case, MudPhud! When you've got a chance, can you post the pt's history, ED course, and disposition? Did you have any trouble converting them to a normal rhythym?

Sorry, just finished a long string of nights. Patient was young(20's) with some sort of cardiomyopathy presenting with palpitations and shortness of breath. My wife saw the case, not me. After a few minutes digging around in the ED for the magnet it was placed upon which the patient converted to a rate of 80 with sequential pacing of the atria and ventricles, the default setting for her pacer. The magnet was then removed, she went into sinus rhthym and she was put in the obs unit so cards could reprogram her pacer in the AM.