Ventricular paced rhythm
Also called pacemaker rhythm.
A narrow vertical pacer spike immediately precedes each wide QRS: the pacemaker, not the AV node, is depolarizing the ventricle. Electrical capture is a wide complex after every spike; mechanical capture is a pulse to match.
How to identify Ventricular paced rhythm
- Rate
- The set pacing rate
- Rhythm
- Regular
- P waves
- None here (the ventricle is paced)
- PR interval
- None
- QRS
- Wide, right after each spike
- Clincher
- A pacer spike immediately before every wide QRS.
Rhythms it gets mistaken for
Ventricular paced rhythm vs Atrial paced rhythm
Ventricular paced rhythm has a pacer spike right before every wide QRS. With an atrial paced rhythm you would see a pacer spike right before every P wave. A wide QRS means the signal started in the ventricles or got there through an abnormal path.
Ventricular paced rhythm vs Idioventricular rhythm
Ventricular paced rhythm has a pacer spike right before every wide QRS. With an idioventricular rhythm you would see no pacer spikes. A pacemaker starts every beat.
Ventricular paced rhythm vs 3rd-degree (complete) AV block
Ventricular paced rhythm has a pacer spike right before every wide QRS. With 3rd-degree block you would see no pacer spikes. A pacemaker starts every beat.
Treatment by certification level
Open your level. Treat the patient, not the strip.
Paramedic
Confirm the pacemaker is doing its job.
- Electrical capture: a wide QRS after every spike. Mechanical capture: a pulse to match.
- Failure to sense: spikes landing on the patient's own beats. Failure to capture: spikes with no complex after them. Failure to pace: no spikes when there should be.
- If you defibrillate, keep the pad at least 1 inch from the implanted device, and never withhold a shock because of it.
AEMT
Pulse present and stable.
- Oxygen only if hypoxic or short of breath, IV access, monitoring.
- Acquire and transmit a 12-lead ECG. Interpreting it is a Paramedic skill.
- Transport and reassess. Request a paramedic if the patient worsens.
EMT
Pulse present: assess and support.
- Treat the patient, not the rhythm name: airway, breathing, circulation, vital signs.
- Oxygen if the SpO2 is under 94%, the patient is short of breath, or shows signs of shock.
- Request ALS and transport promptly. Reassess on the way.
An AED goes only on a patient who is unresponsive, not breathing and pulseless. It cannot feel a pulse, so on a patient with a pulse it can advise a shock that would do harm.