It is important to go through a consistent approach when interpreting pacemaker ECGs, ideally the same one you use for non-paced ECGs. delivering the spike to depolarize the myocardium), or sensing. When it malfunctions, the issue is with rate, pacing, capturing (i.e. the pacemaker or pulse generator) and a lead or leads. Paced, Fusion, and Capture Beats Approach to a Pacemaker ECGĪ pacemaker consists of a box (i.e. It should be narrower and have a different morphology than your paced beats.įigure 1. Capture beats – the native beat breaks through and is conducted by the ventricle.Fusion beats – the native beat and pacemaker beat fuse, causing an odd hybrid QRS complex.Look carefully in each lead to make sure you’re not missing a subtle paced spike! The majority of permanent pacemakers seen in the ED will have leads in the RV and have a LBBB pattern. If, on the other hand, the lead is in the LV, it will produce a right bundle branch block (RBBB) pattern. If a lead is in the right ventricle (RV), it produces a left bundle branch block (LBBB) pattern on ECG, as the paced beat depolarizes across the myocardium.Since the native rhythm is currently normal, the pacemaker isn’t triggered, and instead sits back and senses the rhythm. For example, a patient who has a pacemaker with a currently-appropriate native rhythm may have an ECG that looks like the one above. This ECG shows normal sinus rhythm, and this does not rule out the presence of a pacemaker. His vitals are stable.ĭoes this person actually have a pacemaker? His past medical history is significant for a permanent pacemaker (PPM) that was placed for complete heart block three years ago. The patient is a 68-year-old male with chest pain. It’s Saturday night and you are handed the following ECG. Check out part 1, “ Pacemaker Essentials: What we need to know in the ED” if you haven’t already! If you’d like to download a personal version of the above infographic, click here. Let’s shift our focus to the ECG, and hopefully we’ll discover some pearls to help us with these troublesome devices. Is that pesky pacemaker still causing you trouble? It means well but sometimes it can rub emergency physicians the wrong way.
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