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A 59 year old male collapses at his desk at work. CPR is performed and he is defibrillated with an automatic external defibrillator (AED). He is intubated by the paramedics and brought to the emergency room. His initial ECG follow


performed and he is defibrillated with an automatic external defibrillator (AED). He is intubated by the

paramedics and brought to the emergency room. His initial ECG follows:

What happened?

The underlying rhythm appears to be sinus tachycardia (rate about 130 BPM) with high grade AV block and a slow ventricular rate.


Some of the complexes are premature ventricular beats (green arrows), but the other complexes appear to be conducted (blue arrows).
There is marked ST elevation in lead III and to a lesser extent lead II (blue arrows); there are ** conducted beats in lead aVF. There is marked ST depression in V2 (green arrow). Thus, there is acute inferoposterior infarction. A right sided ECG revealed acute RV infarction ,The presumption was that he had primary ventricular fibrillation in the setting of the acute inferoposterior infarction. The patient was treated with atropine and intrave**us fluid initially, then went emergently to the catheterization laboratory. A temporary pacing wire was placed, and a proximally occluded right coronary artery was opened.
What's the ECG after the pacing wire?

The ECG after the pacing wire was placed follows:


Is there anything unusual about this?
While a paced QRS complex is usually very difficult to assess for ischemia, the signs of acute inferoposterior infarction are present here. **te the ST elevation in leads III and aVF (blue arrows) and mild ST depression in lead V2 (green arrow).
Within 24 hours, Mobitz I 2nd degree A-V block was present; after a**ther 36 hours, the patient had 1:1 conduction with 1st degree AV block. ** further heart block was **ted, and the patient was discharged on day 6 without a pacemaker. As the patient had ** significant ventricular arrhythmias following admission, he was discharged without specific electrophysiologic evaluation. Discharge medications included a beta-blocker, ACE inhibitor, aspirin, and HMG CoA reductase inhibito

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Post CPR