Transcutaneous pacing: “Put it up to eleven!”

What. The. Heck. Dramatic ECG! But there is a short answer, actually just a number. And as the title suggests, the answers to this case are (both literally and figuratively) 11. But what are the questions? The Case EMS brought in a middle-aged male with altered mental status and an ill appearance.Over the past 3-4 days he had become increasingly weak, and now seemed “out of it” to his family. He had a recent admission to the hospital for atrial fibrillation, and was discharged on an ACE inhibitor, as well as both a beta-blocker and a calcium-channel blocker. (No digoxin.) The paramedic found his heart rate to be in the 20s. The ECG: I’m unclear what the BP was, but transcutaneous pacing (TCP) was started. Here is the sequence as the medic raised the mAmps: Pitfalls in Pacing Now, TCP is full of pitfalls, of which the second-largest is failure to capture. The most-largest is, of course, failure to recognize the failure to capture! It’s easy to get wrong, especially since the topic is not well understood, even by many physicians. Did the medics get “true” capture?  Let’s examine the sequence as the amperage is turned up. Native beats First, look at each QRS marked with an inverted triangle. These  native beats are circled with a red circle. They look the same at 10 mA and at 100 mA: a small QRS followed by a long QT interval.   Phantom impulses Next, note the paced complexes (e.g. the complexes with the green arrows) in the 70 m...
Source: EMS 12-Lead - Category: Cardiology Authors: Tags: Uncategorized Source Type: research