Secondary Logo

Journal Logo

Spontaneous Circulation: The Wire

Bruen, Charles MD

doi: 10.1097/01.EEM.0000459010.13730.06
Spontaneous Circulation

Dr. Bruenis a fellow in critical care medicine and emergency cardiology at Hennepin County Medical Center in Minneapolis. He has special interest in stabilization, resuscitation, hemodynamic evaluation, and emergency cardiovascular care. Visit his website,http://resusreview.com, follow him @resusreview, and read his past columns athttp://bit.ly/SponCirc.

Figure 2

Figure 2

Figure

Figure

A patient presented with severe symptomatic bradycardia secondary to hyperkalemia that did not improve with calcium and insulin/glucose. Transcutaneous pacing had poor intermittent capture, so a transvenous pacemaker was placed, and a 12-lead ECG was obtained immediately after. (Figure 1.)

Figure 1

Figure 1

This is an abnormal ECG for a patient undergoing transvenous pacing, and you can determine that the pacer wire is misplaced by the ECG. Pacer spikes appear prior to each QRS complex, but the QRS complex is narrow with an axis downward and to the left, indicating that the lead contact is either atrial or high on the septal wall. A properly placed right ventricular lead placement in the apex should result in a LBBB and an upwards QRS complex.

The pacer wire takes a crazy course, however. It can be seen entering from the top of the film through the right internal jugular vein and descending the SVC (to the right of midline) to the heart. It is coiled in the right ventricle, and part of the wire is likely looping through the tricuspid valve. The electrode tip appears to be abutting the high septal wall. (Figure 2.)

The patient was taken to the cardiac catheterization lab for repositioning of the pacing wire under fluoroscopy. The wire was confirmed to be coiled and almost tied in a knot. The tip was in the atria, and the floating balloon was partially inflated. It was repositioned without difficulty and achieved excellent capture.

Find a complete discussion of placing a transvenous pacemaker in the EMN iPad app and in the Spontaneous Circulation blog on www.EM-News.com, where the EMN app can also be downloaded for free.

Access the linksin EMN by reading this on our website or in our free iPad app, both available atwww.EM-News.com. Comments?Write to us atemn@lww.com.

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.