Emergency Evaluation of 12-Lead ECGs

Carey, Mary G.; Fan, Ted; Pillow, M. Tyson; Al-Zaiti, Salah S.; Kozik, Teri M.; Pelter, Michele

doi:10.4037/ajcc2013945

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ECG Puzzler| May 01 2013

Emergency Evaluation of 12-Lead ECGs

Mary G. Carey, RN, PhD, CNS;

Mary G. Carey, RN, PhD, CNS

Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Ted Fan and M. Tyson Pillow are physicians with the Baylor College of Medicine, Houston, Texas. Salah S. Al-Zaiti is a doctoral student at the School of Nursing, State University of New York at Buffalo. Teri Kozik is supervisor of cardiac research at St. Joseph’s Medical Center, Stockton, California. Michele M. Pelter is an assistant professor at the Orvis School of Nursing, University of Nevada, Reno.

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Ted Fan, MD;

Ted Fan, MD

Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Ted Fan and M. Tyson Pillow are physicians with the Baylor College of Medicine, Houston, Texas. Salah S. Al-Zaiti is a doctoral student at the School of Nursing, State University of New York at Buffalo. Teri Kozik is supervisor of cardiac research at St. Joseph’s Medical Center, Stockton, California. Michele M. Pelter is an assistant professor at the Orvis School of Nursing, University of Nevada, Reno.

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M. Tyson Pillow, MD;

M. Tyson Pillow, MD

Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Ted Fan and M. Tyson Pillow are physicians with the Baylor College of Medicine, Houston, Texas. Salah S. Al-Zaiti is a doctoral student at the School of Nursing, State University of New York at Buffalo. Teri Kozik is supervisor of cardiac research at St. Joseph’s Medical Center, Stockton, California. Michele M. Pelter is an assistant professor at the Orvis School of Nursing, University of Nevada, Reno.

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Salah S. Al-Zaiti, RN, MS, NP;

Salah S. Al-Zaiti, RN, MS, NP

Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Ted Fan and M. Tyson Pillow are physicians with the Baylor College of Medicine, Houston, Texas. Salah S. Al-Zaiti is a doctoral student at the School of Nursing, State University of New York at Buffalo. Teri Kozik is supervisor of cardiac research at St. Joseph’s Medical Center, Stockton, California. Michele M. Pelter is an assistant professor at the Orvis School of Nursing, University of Nevada, Reno.

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Teri M. Kozik, RN, PhD, CNS, CCRN;

Teri M. Kozik, RN, PhD, CNS, CCRN

Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Ted Fan and M. Tyson Pillow are physicians with the Baylor College of Medicine, Houston, Texas. Salah S. Al-Zaiti is a doctoral student at the School of Nursing, State University of New York at Buffalo. Teri Kozik is supervisor of cardiac research at St. Joseph’s Medical Center, Stockton, California. Michele M. Pelter is an assistant professor at the Orvis School of Nursing, University of Nevada, Reno.

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Michele Pelter, RN, PhD

Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Ted Fan and M. Tyson Pillow are physicians with the Baylor College of Medicine, Houston, Texas. Salah S. Al-Zaiti is a doctoral student at the School of Nursing, State University of New York at Buffalo. Teri Kozik is supervisor of cardiac research at St. Joseph’s Medical Center, Stockton, California. Michele M. Pelter is an assistant professor at the Orvis School of Nursing, University of Nevada, Reno.

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Am J Crit Care (2013) 22 (3): 267–268.

https://doi.org/10.4037/ajcc2013945

Scenario: A 45-year-old male with a medical history of lumbar radiculopathy, coronary artery disease, and myocardial infarction with subsequent bradycardia that required an implantable dual-chamber pacemaker arrived at the emergency department complaining of lower back pain. Because of his cardiac history, a resting 12-lead electrocardiogram (ECG) was obtained, but it was evaluated after his back pain was treated and he was discharged. After a cardiologist read the ECG, the patient was immediately called and encouraged to schedule an urgent appointment with his cardiologist. Why was the patient called?

This ECG shows atrial pacing at 70/min with subtle pacemaker spikes on the ascent of the T wave in leads V₂ through V₆. This dual chamber pacemaker is malfunctioning because it is undersensing the QRS complex and fails to be inhibited by the intrinsic cardiac rhythm.

The rare phenomenon of R-on-T occurs when an ectopic beat (intrinsic or artificial)...

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