Truly excellent interpretation by Dr. Joey Freedman.
This is indeed a patient with rapid atrial fibrillation with aberrantly conducted complexes and intermittent biventricular pacing. Whew! Think of atrial fibrillation with rapid ventricular response, but the ventricles are unable to respond quickly, so the rhythm appears wide and similar to ventricular tachycardia. The first QRS complex of the EKG is paced, then a run of unpaced complexes, and finally starts to be paced again just before the middle of the rhythm strip.
Furthermore, this happens to be a patient with ESRD on HD who had hyperkalemia. Dr. Freedman is right! Give calcium, hyperkalemia treatments, and call for dialysis along with your cardiology consult for CCU admission. The afib was difficult to control until after dialysis, metoprolol and amiodarone. The next day he converted back to steady biventricular pacing.
This was his EKG at cardiology follow-up two weeks later, similar to prior EKGs before this hospital admission:
Biventricular pacing, also known as cardiac resynchronization pacing, is indicated for sinus rhythm severe heart failure with a widened QRS, NYHA class III (sometimes IV) and LVEF <35% despite medical optimization with a class A strength of evidence. It can be considered for similar patients in afib instead of sinus, but there is class B evidence. There are select other conditions that may warrant biventricular pacing. The benefits include increased exercise tolerance, improved cardiac output, decrease hospitalization and improved quality of life. Clinical improvement has been demonstrated in several randomized control trials for appropriate patients. You will likely continue to see a widened QRS although it should narrow from pre-paced rhythms.
Heart Failure Society Practice Guidelines, 2010
Martindale, JL and Brown, DFM. Rapid Interpretation of ECGs in Emergency Medicine. LWW: 2012.
Mattu, A and Brady, W. ECGs for the Emergency Physician 2. Blackwell: 2008.
eabram
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1 Comment
Ian deSouza · September 20, 2014 at 11:29 am
Nice one, Freedman! You must be compiling a bunch of those awards. I’d like to see a tally among the residents. Was Reisman on vacation?
And nice explanation too, Abram.