Wandering Atrial Pacemaker - Atrial Rhythms

Description.

  • Rhythms are often named according to the origin of the electrical activity in the heart or the structure where the problem is occurring.
  • Wandering Atrial Pacemaker is aptly named due to the electrical impulses causing the atrial activity are moving or wandering.
  • These changes in the locus of stimulation affect the morphology of the P waves.
  • In Wandering Atrial Pacemaker ECG, you must observe at least three different shaped P waves. No other changes in the tracing may be observed. The rhythm may or may not be regular.
  • The PR interval is often affected, but does not have to be.
  • The bottom line, is you must observe at least three different shaped P waves.

Practice Strip

Analyze this tracing using the five steps of rhythm analysis.

  • Rhythm: Irregular
  • P wave: Changing Shapes (3 or more)
  • PR interval: Variable
  • Interpretation: Wandering Atrial Pacemaker

Authors and Reviewers

  • EKG heart rhythm modules: Thomas O'Brien.
  • EKG monitor simulation developer: Steve Collmann
  • 12 Lead Course: Dr. Michael Mazzini, MD .
  • Spanish language EKG: Breena R. Taira, MD, MPH
  • Medical review: Dr. Jonathan Keroes, MD
  • Medical review: Dr. Pedro Azevedo, MD, Cardiology
  • Last Update: 11/8/2021
  • Electrocardiography for Healthcare Professionals, 6th Edition Kathryn Booth and Thomas O'Brien ISBN10: 1265013470, ISBN13: 9781265013479 McGraw Hill, 2023
  • Rapid Interpretation of EKG's, Sixth Edition Dale Dublin Cover Publishing Company
  • EKG Reference Guide EKG.Academy
  • 12 Lead EKG for Nurses: Simple Steps to Interpret Rhythms, Arrhythmias, Blocks, Hypertrophy, Infarcts, & Cardiac Drugs Aaron Reed Create Space Independent Publishing
  • Heart Sounds and Murmurs: A Practical Guide with Audio CD-ROM 3rd Edition Elsevier-Health Sciences Division Barbara A. Erickson, PhD, RN, CCRN
  • The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds, Murmurs, EKG Jonathan Keroes, David Lieberman Publisher: Lippincott Williams & Wilkin) ISBN-10: 0781784425; ISBN-13: 978-0781784429
  • Project Semilla, UCLA Emergency Medicine, EKG Training Breena R. Taira, MD, MPH
  • ECG Reference Guide PracticalClinicalSkills.com

This website is only for professional medical education. Contact your doctor for medical care. 2024 © MedEdu LLC. All Rights Reserved. Terms & Conditions | About Us | Privacy | Email Us

mededu company logo

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android . Learn more here!

  • Remote Access
  • Save figures into PowerPoint
  • Download tables as PDFs

Quick Dx & Rx: Cardiology

Wandering Atrial Pacemaker

  • Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

  • Search Book

Jump to a Section

Key features, clinical presentation, diagnostic evaluation, ongoing management.

  • Full Chapter
  • Supplementary Content

ESSENTIALS OF DIAGNOSIS

Progressive cyclic variation in P-wave morphology

Heart rate 60–100 bpm

Variation of P-wave morphology, P-P interval, and P-R interval

GENERAL CONSIDERATIONS

This rhythm is benign

This rhythm and multifocal atrial tachycardia are similar except for heart rate

The other possible explanation is that there is significant respiratory sinus arrhythmia, with uncovering of latent foci of pacemaker activity

Usually, it is associated with underlying lung disease

In the elderly, it may be a manifestation of sick sinus syndrome

In the young and athletic heart, it may represent enhanced vagal tone

SYMPTOMS AND SIGNS

Usually causes no symptoms and is incidentally discovered

Occasional patient may feel skipped beats

PHYSICAL EXAM FINDINGS

Variable S 1

DIFFERENTIAL DIAGNOSIS

Multifocal atrial tachycardia (heart rate > 100 bpm)

Frequent premature atrial complexes and atrial bigeminy

LABORATORY TESTS

None specific

ELECTROCARDIOGRAPHY

ECG to document rhythm

CARDIOLOGY REFERRAL

Not required

MEDICATIONS

No specific treatment

Monitor and treat the underlying cause, such as sick sinus syndrome or lung disease

DIET AND ACTIVITY

No restrictions

General healthy lifestyle

Once a year if sinus node abnormality is suspected; otherwise when symptoms arise

COMPLICATIONS

May progress to sick sinus syndrome

This condition by itself is benign

PRACTICE GUIDELINES

Indications for pacemaker:

– If part of sick sinus syndrome

– If associated with documented symptomatic bradycardia

Sign in or create a free Access profile below to access even more exclusive content.

With an Access profile, you can save and manage favorites from your personal dashboard, complete case quizzes, review Q&A, and take these feature on the go with our Access app.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

ECG Interpretation

Thursday, March 4, 2021

Blog #200 — wandering pacemaker (vs mat).

There is no clinical information is available for the ECG and 2-lead rhythm strip shown below in  Figure-1 .

  • HOW would you interpret this tracing?
  • What treatment is likely to be needed? 

====================================

Editorial  Comment:

It is always challenging to interpret tracings without the benefit of clinical information. That said — this situation is common in clinical practice. My experience in this area derives from the 30 years during which I was charged with interpreting  all  ECGs ordered by 35 medical providers at a primary care clinic — as well periodic stints during which I interpreted hospital tracings without the benefit of any history. 

  • The challenge lies with having to decide  which  tracings in the  “pile of ECGs to be interpreted”  were those for which I needed to pull the medical chart ( or call the provider ) because of ECG findings of immediate potential concern.
  • Obvious time constraints made it impossible to pull the chart for each ECG that I was given to read ( I’d never get anything else done if I did so ).
  • I therefore became well versed in the skill of limiting the charts that I would pull to those patients whose ECGs showed findings I thought were important  and  potentially indicative of an acute situation that may have been overlooked.

=====================================

MY Thoughts  on the ECG in Figure-1:

As always — systematic interpretation of  any  ECG should begin with assessing the cardiac rhythm. In general —  lead II  and  lead V1  are the 2  best  leads on a 12-lead tracing for assessing atrial activity — and we have the advantage in  Figure-1  of a  simultaneously-recorded  2-lead rhythm strip of both of these leads.  By the  Ps ,  Qs and  3R Approach:

  • The rhythm in  Figure-1  is  clearly   irregular .
  • The  QRS  complex is  narrow ( ie,  not  more than half a large box in duration = ≤0.10 second ) . 
  • The rate  varies  from  50 /minute — to just under  100 /minute.
  • More than 1 P wave morphology is present . That said — P waves  do  appear to be related to neighboring QRS complexes, because the PR interval for the P wave shapes that we see remains constant  ( See   Figure-2 ) .

MY Thoughts  on Figure-2:

There are 2 different P wave shapes in  Figure-2 .

  • The tracing begins with  3  sinus  beats ( ie,  RED arrows highlight 3 similar-looking upright-in-lead-II P waves — all with the same PR interval ) .
  • P wave shape then changes  for beats #4, 5 and 6  ( ie,  BLUE arrows highlighting an almost isoelectric, if not negative P wave with fixed PR interval ) .
  • The atrial focus then shifts back , with return to sinus P waves for beats #7, 8, 9 and 10 (ie,  return of RED arrows highlighting similar-looking, upright P waves in lead II — albeit with variability in the R-R interval ).
  • The rhythm in  Figure-2  concludes with a  slowing-down  of the ventricular rate, as  the 2nd atrial focus returns , in which the P wave is almost isoelectric (ie,  BLUE arrows for beats #11 and 12 ).

BOTTOM LINE  regarding  Figure-1:  The rhythm in  Figure-2  is most consistent with a  Wandering  Atrial  Pacemaker . This is because the change from one atrial site to the next occurs gradually over a period of several beats.

  • PEARL:  The reason it is uncommon ( if not rare ) in clinical practice to see a wandering atrial pacemaker — is that most providers do not pay  long enough  attention to  beat-to-beat  change in P wave morphology needed to identify  gradual  shift between  at least  3 different atrial sites.

SUMMARY:  Review of the  KEY  features of wandering atrial pacemaker is the theme below for our  ECG  Media  Pearl #17 ( a 3:30 minute audio recording ).

  • Written review of wandering pacemaker appears below in  Figure-3 .
  • Review of  MAT  is covered in our  ECG Blog #199 .

wandering pacemaker rhythm strip

Today’s   E CG  M edia   P EARL  # 17 ( 3:30 minutes   Audio )  —   What is a  Wandering  Atrial Pacemaker ( as opposed to MAT )?

wandering pacemaker rhythm strip

A DDENDUM   ( 3/4/2021 ) :

I received the following note from  David Richley  regarding today’s tracing: “I think I would use different terminology to describe this because to me the atrial pacemaker doesn’t so much ‘wander’ as ‘jump’. I would describe this as sinus arrhythmia with junctional escape rhythm at 60-65/minute every time the sinus node discharge rate slows to below that rate. I interpret the escape beats as junctional rather than atrial, because athough the P waves, ( which are initially negative in II, aVF and V4-V6 — and positive in aVR ) precede the QRS — the PR segment is very short, suggesting an AV nodal origin. However, we describe this phenomenon — I do agree that it’s likely to be completely benign.

MY Thoughts:  Dave’s comment is one of the reasons why:  i )  The diagnosis of wandering pacemaker requires clear demonstration of shift in the atrial pacemaker in  at least  3 different sites. We  only  see 2 different sites here;  and ,  ii )  The diagnosis of wandering atrial pacemaker is  not  common. 

  • It’s impossible to rule out Dave’s theory from the single tracing we have.
  • That said — the BLUE arrow P wave site may or may not be of AV nodal origin ( you can see a similar, near-isoelectric P wave with short PR interval from a low atrial site ).
  • I also considered the possibility of the BLUE arrow P waves representing junctional escape — but decided against it because the difference in R-R interval from what we see between beats #9-10  vs  what we see between beats #10-11 is  more  than what I’d expect based on the cadence of rate variation I see from beats #7-10.
  • Bottom Line:  We both agree there is a shift in the pacemaker site in a rhythm that is likely to be benign. And, we both agree that additional monitoring would be needed for a definitive response.  THANK YOU Dave!

No comments:

Post a comment.

ECG Educator Blog

ECG Education to help save more lives @ECGEducator, @JasonWinterECG

  • Published Articles
  • Facebook ECG Group
  • ECG FB Group
  • ECG Educator FB Page
  • ECG & Cardiology FB Page
  • Medical illustrations
  • ECG Rhythm Strips
  • www./paypalme/ECG1
  • ECG Study PDF’s

Sunday 13 November 2016

Wandering atrial pacemaker (wap).

wandering pacemaker rhythm strip

No comments:

Post a comment.

WikEM

  • Mobile Apps
  • Journal Club
  • Antibiotics
  • Quick Critical Care
  • Residency Directory
  • Recent Changes
  • About WikEM
  • Getting Started
  • Creating & Editing
  • Needed Pages
  • Editorial Levels
  • Contribution Score
  • Elective Guide
  • Citing WikEM
  • What links here
  • Related changes
  • Special pages
  • Printable version
  • Permanent link
  • Page information
  • Browse properties

Harbor-UCLA

  • View source
  • View history
  • Create account

WikEM

We need you! See something you could improve? Make an edit and help make WikEM better for everyone.

  • Wandering atrial pacemaker
  • 2 Clinical Features
  • 3.1 Palpitations
  • 4.2 Diagnosis
  • 5 Management
  • 6 Disposition
  • 8 External Links
  • 9 References
  • Three or more ectopic foci within the atrial myocardium serve as the pacemaker
  • Rate is less than 100bpm (in contrast to MAT )
  • Is irregularly irregular therefore sometimes confused with atrial fibrillation and sinus arrhythmia
  • Intrinsic cardiac or pulmonary disease
  • Metabolic derangements
  • Drug toxicity (including Digoxin )

Clinical Features

  • Often seen in the extremes of age and in athletes
  • Rarely causes symptoms

Differential Diagnosis

Palpitations.

  • Narrow-complex tachycardias
  • Wide-complex tachycardias
  • Second Degree AV Block Type I (Wenckeback)
  • Second Degree AV Block Type II
  • Third Degree AV Block
  • Premature atrial contraction
  • Premature junctional contraction
  • Premature ventricular contraction
  • Sick sinus syndrome
  • Acute coronary syndrome
  • Cardiomyopathy
  • Congenital heart disease
  • Congestive heart failure (CHF)
  • Mitral valve prolapse
  • Pacemaker complication
  • Pericarditis
  • Myocarditis
  • Valvular disease
  • Panic attack
  • Somatic Symptom Disorder
  • Drugs of abuse (e.g. cocaine )
  • Medications (e.g. digoxin , theophylline )
  • Thyroid storm
  • Pulmonary embolism
  • Dehydration
  • Pheochromocytoma

Wandering atrial pacemaker.JPG

  • ECG should show three distinct P wave morphologies with a ventricular rate <100bpm
  • Rarely requires treatment

Disposition

  • Outpatient management
  • Multifocal atrial tachycardia
  • Dysrhythmia

External Links

  • Richard Cunningham
  • fardis tavangary
  • Ross Donaldson
  • Privacy policy
  • Disclaimers

LITFL-Life-in-the-FastLane-760-180

Pacemaker Malfunction

  • Ed Burns and Robert Buttner
  • Jun 4, 2021

Pacemaker Malfunction Overview

  • Pacemaker malfunction can occur for a wide variety of reasons, ranging from equipment failure to changes in underlying native rhythm.
  • Diagnosis of pacemaker malfunction is challenging and often associated with non-specific clinical symptoms while ECG changes can be subtle or absent.

Note: Normal pacemaker function is discussed extensively in a seperate post.

Problems with Sensing

Undersensing

  • Undersensing occurs when the pacemaker fails to sense native cardiac activity.
  • Results in asynchronous pacing.
  • Causes include increased stimulation threshold at electrode site (exit block), poor lead contact, new bundle branch block or programming problems.
  • ECG findings may be minimal, although presence of pacing spikes within QRS complexes is suggestive of undersensing.

Oversensing

  • Oversensing occurs when electrical signal are inappropriately recognised as native cardiac activity and pacing is inhibited.
  • These inappropriate signals may be large P or T waves, skeletal muscle activity or lead contact problems.
  • Abnormal signals may not be evident on ECG.
  • Reduced pacemaker output / output failure may be seen on ECG monitoring if the patient stimulates their rectus or pectoral muscles (due to oversensing of muscle activity).

Problems with Pacing

Output failure

  • Output failure occurs when a paced stimulus is not generated in a situation where expected.
  • Results in decreased or absent pacemaker function.
  • Multiple causes including oversensing, wire fracture, lead displacement, or interference.

Failure to capture

  • Failure to capture occurs when paced stimulus does not result in myocardial depolarisation.
  • Multiple causes including electrode displacement, wire fracture, electrolyte disturbance, MI or exit block.

NB. If the patient’s native heart rate is above the pacemaker threshold, no pacemaker activity is expected and therefore output failure and capture failure cannot be recognised on the ECG.

Pacemaker Associated Dysrhythmias

Several types of pacemaker associated dysrhythmias can occur including pacemaker-mediated tachycardia (PMT), sensor-induced tachycardia, runaway pacemaker, pacemaker-mediated Wenckebach AV block and lead dislodgement dysrhythmia.

Pacemaker-mediated tachycardia (PMT)

  • Also known as endless-loop tachycardia or pacemaker circus movement tachycardia.
  • PMT is a re-entry tachycardia in which the pacemaker forms the antegrade pathway with retrograde conduction occurring via the AV node.
  • Caused by retrograde p waves being sensed as native atrial activity with subsequent ventricular pacing.
  • The paced ventricular complex results in further retrograde conduction with retrograde p wave generation thus forming a continuous cycle.
  • Results in a paced tachycardia with the maximum rate limited by the pacemaker programming.
  • Can be terminated by slowing AV conduction e.g. adenosine or activation of magnet mode.
  • Newer pacemakers contain programmed algorithms designed to terminate PMT.
  • May result in rate related ischaemia in the presences of IHD.

Sensor-induced tachycardia

  • Modern pacemakers are programmed to allow increased heart rates in response to physiological stimuli such as exercise, tachypnoea, hypercapnia or acidaemia.
  • Sensors may “misfire” in the presence of distracting stimuli such as vibrations, loud noises, fever, limb movement, hyperventilation or electrocautery (e.g. during surgery).
  • This misfiring leads to pacing at an inappropriately fast rate.
  • The ventricular rate cannot exceed the pacemaker’s upper rate limit (usually 160-180 bpm).
  • These will also usually terminate with application of a magnet.

Runaway pacemaker

  • This potentially life-threatening malfunction of older-generation pacemakers is related to low battery voltage (e.g. overdue pacemaker replacement).
  • The pacemaker delivers paroxysms of pacing spikes at 200 bpm, which may provoke ventricular fibrillation.
  • Paradoxically, there may be failure to capture — causing bradycardia — because the pacing spikes are very low in amplitude (due to the depleted battery voltage) and because at very high rates the ventricle may become refractory to stimulation.
  • Application of a magnet can be life saving but definitive treatment requires replacement of the pacemaker.
  • Some great cases of runaway pacemaker are discussed here .

Lead displacement dysrhythmia

  • A dislodged pacing lead may float around inside the right ventricle, intermittently “tickling” the myocardium and causing ventricular ectopics or runs of VT (in much the same way as the guide wire of a central line!), alternating with failure of capture.
  • If the paced QRS morphology changes from a LBBB pattern (indicating RV placement) to a RBBB pattern (indicating LV placement), this suggests that the electrode has eroded through the interventricular septum.
  • A chest x-ray will usually help to confirm the diagnosis.

Pacemaker Syndrome

  • Caused by improper timing of atrial and ventricular contractions resulting in AV dyssynchrony and loss of atrial “kick”.
  • Variety of clinical symptoms including fatigue, dizziness, palpations, pre-syncope.
  • Associated decrease in systolic blood pressure > 20 mmHg during change from native rhythm to paced rhythm.

Twiddler’s Syndrome

  • Patient manipulation of the pulse generator (accidentally or deliberately).
  • The pacemaker rotates on its long axis, resulting in dislodgement of pacing leads.
  • Can result in diaphragmatic or brachial plexus pacing (e.g. arm twitching) depending on extent of lead migration.

ECG in Pacemaker Malfunction

  • Normal pacemaker rhythms can result in absent pacing activity, irregular pacing and absence of pacing spikes.
  • Diagnosis of pacemaker malfunction on the ECG is very difficult and may be impossible depending on the underlying native rhythm.
  • If pacemaker malfunction is suspected cardiology review is required to facilitate pacemaker interrogation and testing.

ECG Examples

pacemaker-failure 2

Pacing failure: This ECG shows a ventricular paced rhythm with intermittent failure to capture:

  • Atrial sensing appears to be intact — ventricular pacing spikes follow each P wave, most easily seen in V3-6 (tiny pacing spikes are also visible in I, aVR and V1).
  • There is presumably an underlying complete heart block or high-grade 2nd degree AV block , as the native P waves do not capture the ventricles.

PMT Pacemaker-mediated tachycardia

Rapid ventricular pacing

There is a rapid ventricular-paced rhythm (120 bpm) with no evidence of preceding atrial activity (except for the first complex). The differential diagnosis of this rhythm would include:

  • Pacemaker-mediated tachycardia (with retrograde P waves buried in the QRS complexes /T waves).
  • Sensor-induced tachycardia.
  • Could potentially be normal in the presence of an appropriate physiological stimulus (e.g. exercise).

Example 3 – Runaway pacemaker

runaway-pacemaker 2

  • Paroxysms of rapid pacing spikes at 2000 bpm with decreasing amplitude and rate — this fails to excite the ventricles due to the low amplitude spikes.
  • The underlying rhythm is atrial flutter with 3rd degree AV block and ventricular escape rhythm at 30 bpm.
  • In the middle, three pacing spikes are seen at 60 ppm in VOO mode: the first is ventricular refractory (failed capture).

This ECG and interpretation is reproduced from Ortega et al. (2005).

Related Topics

  • Pacemaker essentials: Medmastery
  • Pacemaker rhythms: Normal pacemaker function
  • Nicholson WJ, Tuohy KA, Tilkemeier P. Twiddler’s Syndrome N Engl J Med 2003; 348:1726-1727.
  • Ortega DF, Sammartino MV, Pellegrino GM, Barja LD, Albina G, Segura EV, Balado R, Laiño R, Giniger AG. Runaway pacemaker: a forgotten phenomenon? Europace. 2005 Nov;7(6):592-7. Epub 2005 Sep 8. PubMed PMID: 16216762

Advanced Reading

  • Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
  • Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course : Become an ECG expert. Medmastery
  • Kühn P, Houghton A. ECG Mastery: Black Belt Workshop . Advanced ECG interpretation. Medmastery
  • Rawshani A. Clinical ECG Interpretation ECG Waves
  • Smith SW. Dr Smith’s ECG blog .
  • Zimmerman FH. ECG Core Curriculum . 2023
  • Mattu A, Berberian J, Brady WJ. Emergency ECGs: Case-Based Review and Interpretations , 2022
  • Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
  • Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine . 1e, 2020
  • Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care . 2e, 2019
  • Hampton J, Adlam D. The ECG Made Practical 7e, 2019
  • Kühn P, Lang C, Wiesbauer F. ECG Mastery: The Simplest Way to Learn the ECG . 2015
  • Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
  • Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
  • Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004

LITFL Further Reading

  • ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
  • ECG A to Z by diagnosis – ECG interpretation in clinical context
  • ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
  • 100 ECG Quiz – Self-assessment tool for examination practice
  • ECG Reference SITES and BOOKS – the best of the rest

ECG LIBRARY

' src=

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

wandering pacemaker rhythm strip

Robert Buttner

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library . Twitter: @rob_buttner

One comment

I have to say I haven’t read all of this but the content makes me cringe at times Ed, just reading about under/oversensing. Pacing spikes within QRS may mimick undersensing, well that is not quite right. More commonly people are having Carts for heart failure and actually as part of the response to intrinsic activation most companies have algorithms in place to offer some form of biV pacing in response to these for example conducted AF which naturally is a fast conducted rhythm. Secondly it’s like pseudo malfunction as the leads based on position don’t sense until the intrinsic A or V event has started so you might get pseudofusion which is entirely normal.

You say about large P waves being an issue for oversensing which I can only assume you mean for crosstalk right (being sensed in the V). This isn’t really an issue anymore due to effective blanking periods namely PAVB in this case preventing cross talk as the V is functionally blanked during this period. I have to say other content as well such as runaway PPMs don’t really occur unless the device has been significantly damaged by say radiation of high frequency and 2000 bpm… Come on I think at times you’re trying to scare people reading this, I worry that physiologists everywhere will get inundated with queries as people will be reading this on your site.

Leave a Reply Cancel reply

This site uses Akismet to reduce spam. Learn how your comment data is processed .

U.S. flag

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

  • Advanced Search
  • Journal List
  • v.13(9); 2021 Sep

Logo of cureus

Electrical Injury and Wandering Atrial Pacemaker

Ranjan k singh.

1 Internal Medicine, Anti-Retroviral Therapy Centre, District Hospital, Khagaria, IND

The supply of household electricity remains a low-voltage (110-220 V) energy source, and its effects on the human body depend on several factors, including the type of contact and duration of contact, among other things. In a significant number of cases, direct contact with household electricity causes reversible cardiac arrhythmia-ventricular fibrillation, ventricular premature beats, atrial tachycardia, and atrial fibrillation.

Wandering atrial pacemaker (WAP) is a benign atrial arrhythmia observed in elderly patients suffering from obstructive pulmonary diseases that result from an ischemic heart. This report discusses WAP as observed in a patient who suffered an electrical injury.

Introduction

The effects of electrical injury vary from skin burn to internal organ damage directed especially at the cardiovascular and nervous systems. The extent of electrical injury depends on the type of electricity source, i.e., direct current (DC) or alternating current (AC), the duration of contact with the source of electricity, the state of the body whether wet or dry, the presence of calluses over the palm, the route of electrical flow, and the level of voltage [ 1 ]. The severity of an electric shock depends on the current flow (I) measured in ampere (A). It is linked to the resistance of the conductor (R, unit: ohm ‘W’) and the potential difference between the two ends of a conductor (Volt; unit V), and is derived by applying the formula based on Ohm’s law: i.e., I = V/R. The severity of an electrical burn, by contrast, depends on the energy (Watt) and is derived from Joule’s formula W=I2 x R x T (duration of exposure with the source of current).

Household electrical supply is a low-voltage (220 V) AC at 60 Hz frequency. The physiological effects of contact with a low-frequency AC (60 Hz) current vary at different amperes. For example, 1mA (1/1000 A) is barely perceptible as numbness, whereas 20 mA can cause respiratory muscle paralysis, while 100 mA reaches a threshold for ventricular fibrillation [ 1 , 2 ]. The resulting cardiac arrhythmia may take the form of ventricular fibrillation, ventricular tachycardia, ventricular premature beats, atrial premature beats, atrial arrhythmia, and/or heart block [ 2 ].

Case presentation

A 40-year-old male patient was brought into the emergency ward after suffering an accidental electrical injury that involved an entry wound in the middle of his left hand and an exit wound in the back of his chest. He was holding the hanging rod for a ceiling fan when the connection was plugged in, resulting in electric shock. He lost consciousness and fell to the ground with the rod clenched in his hand for a minute and a half. The electricity source was disconnected and cardiopulmonary resuscitation was administered to the patient by his neighbors. The patient regained consciousness and complained of aching all over the body along with general weakness. 

He had a black hole in the middle of his left palm (Figure ​ (Figure1A) 1A ) and a linear burn on the back of his chest (Figure ​ (Figure1B 1B ).

An external file that holds a picture, illustration, etc.
Object name is cureus-0013-00000018335-i01.jpg

His pulse was irregularly irregular at 78/minute, and his blood pressure was 110/78 mm Hg. His total leucocyte count was 8600/cmm with neutrophils at 64%, and his hemoglobin was 13 gm/dL. Urinalysis did not show myoglobin. Serum sodium and potassium were 134 mEq/L and 4.2 mEq/L, respectively. Electrocardiography (ECG) showed occasional ventricular premature beat with wandering atrial pacemaker (Figures ​ (Figures2A 2A - ​ -2B). 2B ). Of note, the patient did not have any kind of cardiac ailment previously. The patient was hydrated with intravenous fluids and his wounds were treated with antiseptic dressings and antibiotics. He remained under observation for 48 hours and the ECG showed sinus rhythm (Figure ​ (Figure2C 2C ).

An external file that holds a picture, illustration, etc.
Object name is cureus-0013-00000018335-i02.jpg

Low voltage currents cause severe electrical burns to the skin as a result of high energy output from the current flow. Dry skin with callouses over palm (resistance of 500 W) and a long contact of palm with the source of electricity attribute to severe burn in this patient (Joule formula). Thereby, the electrical energy output is dissipated and there is less internal injury [ 3 , 4 ].

Low voltage currents travel through the body along low-resistance pathway nerves and blood vessels to cause severe cardiac injury. Also, the distance between the entry and exit wounds can determine the severity of the cardiac injury. The heart remains in the central location of the electrical current’s pathway between the left palm and back of the chest. Current spikes occur in the palm and fingers of an individual holding a metal rod that is suddenly connected to an electric source [ 5 ]. The electric shock causes depolarisation of cardiac muscles and increases membrane pores of the cells resulting in arrhythmias; sinus tachycardia, ventricular premature beats, ventricular tachycardia, and atrial fibrillation are common [ 6 , 7 ]. Wandering atrial pacemaker (WAP) is a benign atrial arrhythmia that has been observed in this case study. WAP and multifocal atrial tachycardia (MAT) differ only with the heart rate - WAP has a heart rate less than 100 bpm whereas MAT has a heart rate greater than 100 bpm. In the WAP rhythm, the pacemaker wanders with the impulses originating from the sinoatrial node to the atrium, and to the atrioventricular junction with a changing focus. Hence, the P waves on an ECG are presented in different configurations. WAP is differentiated from sinus arrhythmia by the fact that heart rate variability occurs from beat-to-beat, and is not phasic. Also, in sinus arrhythmia, the P-wave morphology and the P-R interval are constant [ 7 ]. Most of the arrhythmias occur soon after electric shock and are short-lived. However, delayed arrhythmias occurring 12 hours after electric shock have been reported, too [ 8 ].

Conclusions

Household electric supply is low voltage AC of 60 Hz. It is the electric current that determines the pathophysiological effects in the body but the voltage does determine the outcome of electric shock. Even a low-voltage shock can cause ventricular fibrillation if resistance is low and current flow reaches a threshold of 100 mA. The severity of burn lesion is determined by the resistance of skin and duration of exposure with the source of current. Most cardiac arrhythmias are short-lived and do not require treatment.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study. NA issued approval NA. This is a case report.

Atrial Rhythms Module

Atrial dysrhythmias.

Thomas E. O'Brien AS CCT CRAT RMA

Learning Objectives

At the conclusion of this training module the reader will be able to:

  • Recall and apply the 5-steps of heart rhythm interpretation
  • Recognize the difference between regular and irregular rhythms
  • Recall the normal range for PR interval and QRS complex
  • Recognize the features and qualifying criteria for the following complexes and rhythms:
  • Premature Atrial Complexes
  • Wandering Atrial Pacemaker Rhythm

Multifocal Atrial Tachycardia

  • Atrial Flutter
  • Atrial Fibrillation

Authors and Reviewers

  • EKG heart rhythm modules: Thomas O'Brien
  • Medical review: Dr. Jonathan Keroes, MD
  • Medical review: Dr. Pedro Azevedo, MD, Cardiology
  • Last Update: 11/8/2021
  • Electrocardiography for Healthcare Professionals, 6th Edition Kathryn Booth and Thomas O'Brien ISBN10: 1265013470, ISBN13: 9781265013479 McGraw Hill, 2023
  • Rapid Interpretation of EKG's, Sixth Edition Dale Dublin Cover Publishing Company
  • EKG Reference Guide EKG.Academy
  • 12 Lead EKG for Nurses: Simple Steps to Interpret Rhythms, Arrhythmias, Blocks, Hypertrophy, Infarcts, & Cardiac Drugs Aaron Reed Create Space Independent Publishing
  • The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds, Murmurs, EKG Jonathan Keroes, David Lieberman Publisher: Lippincott Williams & Wilkin) ISBN-10: 0781784425; ISBN-13: 978-0781784429
  • ECG Reference Guide PracticalClinicalSkills.com

Lesson #1: Rhythm Analysis Method 312

The five steps of rhythm analysis will be followed when analyzing any rhythm strip.

  • Analyze each step in the following order.

Rhythm Regularity

  • P wave morphology
  • P R interval or PRi
  • QRS complex duration and morphology
  • Carefully measure from the tip of one R wave to the next, from the beginning to the end of the tracing.
  • A rhythm is considered “regular or constant” when the distance apart is either the same or varies by 1 ½ small boxes or less from one R wave to the next R wave.

Heart Rate Regular (Constant) Rhythms

  • The heart rate determination technique used will be the 1500 technique.
  • Starting at the beginning of the tracing through the end, measure from one R wave to the next R wave (ventricular assessment), then P wave to P wave (atrial assessment), then count the number of small boxes between each and divide that number into 1500. This technique will give you the most accurate heart rate when analyzing regular heart rhythms. You may include ½ of a small box i.e. 1500/37.5 = 40 bpm (don’t forget to round up or down if a portion of a beat is included in the answer).

Step 2 (Cont)

Heart rate - irregular rhythms.

  • If the rhythm varies by two small boxes or more, the rhythm is considered “irregular”.
  • The heart rate determination technique used for irregular rhythms will be the “six-second technique”.
  • Simply count the number of cardiac complexes in six seconds and multiply by ten.

P wave Morphology (shape)

  • Lead II is most commonly referenced in cardiac monitoring
  • In this training module, lead two will specifically be referenced unless otherwise specified.
  • The P wave in lead II in a normal heart is typically rounded and upright in appearance.
  • Changes in shape must be reported. This can be an indicator that the locus of stimulation is changing or the pathway taken is changing.
  • P waves may come in a variety of morphologies i.e. rounded and upright, peaked, flattened, notched, biphasic(pictured), inverted and even buried or absent!
  • Remember to describe the shape. This can be very important to the physician when diagnosing the patient.

PR interval (PRi)

  • Measurement of the PR interval reflects the amount of time from the beginning of atrial depolarization to the beginning of ventricular depolarization.
  • Plainly stated, this measurement is from the beginning of the P wave to the beginning of the QRS complex.
  • The normal range for PR interval is: 0.12 – 0.20 seconds (3 to 5 small boxes)
  • It is important that you measure each PR interval on the rhythm strip.
  • Some tracings do not have the same PRi measurement from one cardiac complex to the next. Sometimes there is a prolonging pattern, sometimes not.
  • If the PR intervals are variable, report them as variable, but note if a pattern is present or not.

QRS complex

  • QRS represents ventricular depolarization.
  • It is very important to analyze each QRS complex on the tracing and report the duration measurement and describe the shape (including any changes in shape).
  • As discussed in step 3, when referring to P waves, remember changes in the shape of the waveform can indicate the locus of stimulation has changed or a different conduction pathway was followed. It is no different when analyzing the QRS complex. The difference is that in step 3, we were looking at atrial activity. Now we are looking at ventricular activity.
  • Measure from the beginning to the end of ventricular depolarization.
  • The normal duration of the QRS complex is: 0.06 – 0.10 second

Lesson #2: Interpretation 312

Introduction.

  • The previous slides presented the five-steps of rhythm analysis. These five steps must be followed regardless of how simple of complex the tracing is you are reviewing.
  • The information gathered in these steps are telling a story.
  • The title of that story is the interpretation.

Atrial Dysrhythmias Types

The dysrhythmias in this category occur as a result of problems in the atria. These atrial dysrhythmias primarily affect the P wave. We will be discussing the following complexes and rhythms:

  • Premature Atrial Complexes (PAC’s)
  • Wandering Atrial Pacemaker

Lesson #3: Premature Atrial Complex

Intro to pacs.

  • PACs can occur for a number of different reasons i.e., diet, fatigue, stress, disease, ischemia to name a few.
  • Premature complexes frequently occur in bradycardic rhythms, but may occur almost any time.
  • PACs occur when an early electrical impulse occurs from a location in the atria other than the SA node.

Intro to PACs 2

  • This early impulse causes an early cardiac complex which disrupts the underlying rhythm.
  • The locus of stimulation being different, results in a change in the morphology of the P wave.
  • PACs can occur occasionally or frequently.
  • PACs ECG can be observed with or without a pattern
  • The P wave with PAC's will always be upright

EKG Analysis

Notice the following: the R to R interval is irregular, the fifth complex is early and the P wave on the early complex is a different shape.

EKG Practice Strip

Analyze this tracing using the five steps of rhythm analysis.

  • Rhythm: Irregular
  • P wave: Upright & uniform (except early complexes - biphasic)
  • PR interval: 0.16 second
  • Interpretation: Sinus Bradycardia with PACs

Lesson #4: Wandering Atrial Pacemaker

Description.

  • Rhythms are often named according to the origin of the electrical activity in the heart or the structure where the problem is occurring.
  • Wandering Atrial Pacemaker is aptly named due to the electrical impulses causing the atrial activity are moving or wandering.
  • These changes in the locus of stimulation affect the morphology of the P waves.
  • In Wandering Atrial Pacemaker ECG, you must observe at least three different shaped P waves. No other changes in the tracing may be observed. The rhythm may or may not be regular.
  • The PR interval is often affected, but does not have to be.
  • The bottom line, is you must observe at least three different shaped P waves.

Practice Strip

  • P wave: Changing Shapes (3 or more)
  • PR interval: Variable
  • Interpretation: Wandering Atrial Pacemaker

Lesson #5: Multifocal Atrial Tachycardia

  • Multifocal Atrial Tachycardia is just a faster version of Wandering Atrial Pacemaker. The criteria is the same as Wandering Atrial Pacemaker with the only difference being the heart rate exceeds 100 bpm.
  • These changes in the locus of stimulation within the atria affect the morphology of the P waves.
  • Remember, you must observe at least three different shaped P waves.
  • Due to the presence of irregular R to R intervals coupled with the changing P wave morphology, some people have confused this rhythm with Atrial Fibrillation.

Lesson #6: Atrial Flutter

  • Atrial Flutter (sometimes called a flutter) occurs when there is an obstruction within the atrial electrical conduction system.
  • Due to this impediment a series of rapid depolarizations occur.
  • These depolarizations may occur two, three, four or more times per QRS complex.
  • The AV node functions like a “gatekeeper” blocking the extra impulses until the ventricular conduction system is able to accept the impulse.
  • The impulse that is accepted will cause the QRS complex to occur.
  • Each atrial flutter ECG wave represents atrial depolarization. This will be noted next to the P wave step in rhythm analysis. Instead of P waves, this tracing has “F” waves. No P waves mean there is no PR interval measurement.
  • When the tracing is interpreted, the ratio of F waves to each QRS complex will be documented along with the rhythm i.e. Atrial Flutter 4:1 (indicates 4 “F” waves to each QRS complex). Not all Atrial Flutter rhythm strips will have a regular rhythm. In that case just document and report your observations.
  • Compare your answers with the answers on the next slide.

Practice Strip Answers

  • Rhythm: Regular
  • Rate: Ventricles - 80, Atria - 320
  • P wave: "F" waves
  • PR interval: absent
  • Interpretation: Atrial Flutter 4:1

Lesson #7: Atrial Fibrillation

  • Atrial Fibrillation (afeb) occurs when multiple electrical impulses occur within the atria. This chaotic electrical activity results in a chaotic wave form between the QRS complexes. P waves are absent. They are replaced by lower case "f" waves. No P waves means there is no PR interval measurement.
  • This rapid electrical activity overwhelms the AV node causing impulses to enter the ventricular conduction system at irregular points. This results in irregular R to R intervals.
  • Not all fibrillatory waves are created equal. The "f" waves can be coarse (majority measure 3 mm or more) or can be fine (majority of waveforms measure less than 3 mm) to almost absent. Regardless always report your observations. Many times when a patient has "new onset" Atrial Fibrillation the patient will report with a heart rate of 160 bpm or more.
  • When a patient experiences A-fib, the atria are not contracting as they normally would. They are just quivering. This absence of contraction of the atria can result in a loss of cardiac output anywhere from 15 - 30% due to the absence of "atrial kick". This is why the heart rate is so high. The body is trying to maintain homeostasis.
  • It will be impossible to determine the atrial rate. You will only be able to analyze and report the ventricular rate.
  • Atrial Fibrillation with a ventricular response in excess of 100 bpm is commonly referred to as Atrial Fibrillation with “rapid ventricular response” or "uncontrolled A-fib".
  • Rate: Ventricles - 90, Atria - Unable to determine (UTD)
  • P wave: "f" waves
  • Interpretation: Atrial Fibrillation

Lesson #8: Quiz Test Questions 312

This website provides professional medical education. For medical care contact your doctor. 2024 ©MedEdu LLC. All Rights Reserved. Terms & Conditions | About Us | Privacy | Email Us | 1

mededu company logo

Free Web Hosting

IMAGES

  1. ECG Educator Blog : Wandering Atrial Pacemaker (WAP)

    wandering pacemaker rhythm strip

  2. WAP

    wandering pacemaker rhythm strip

  3. Wandering atrial pacemaker

    wandering pacemaker rhythm strip

  4. Wandering Atrial Pacemaker Rhythm Strip

    wandering pacemaker rhythm strip

  5. Wandering Atrial Pacemaker Rhythm Strip

    wandering pacemaker rhythm strip

  6. Wandering Atrial Pacemaker Rhythm Strip

    wandering pacemaker rhythm strip

COMMENTS

  1. Wandering Atrial Pacemaker EKG Interpretation with Rhythm Strip

    This article is a guide for interpreting abnormal Wandering Atrial Pacemaker EKGs, including qualifying criteria and a sample EKG rhythnm strip. Wandering atrial pacemaker is an arrhythmia originating in shifting pacemaker sites from the SA node to the atria and back to the SA node. On an ECG, the p-waves reflect the pacemaker shifts by shape variations. The PRI interval may vary from one beat ...

  2. Wandering Atrial Pacemaker (WAP) ECG Review

    Wandering Atrial Pacemaker (WAP) ECG Review | Learn the Heart - Healio

  3. Wandering Atrial Pacemaker ECG Interpretation with Sample Strip

    Wandering Atrial Pacemaker Rhythm Strip Features. Rate: Normal (60-100 bpm) Rhythm: May be irregular. P Wave: Changing shape and size from beat to beat (at least three different forms) PR Interval: Variable. QRS: Normal (0.06-0.10 sec) The electrical impulses causing the atrial activity are moving or wandering.

  4. Wandering atrial pacemaker

    Wandering atrial pacemaker (WAP) is an atrial rhythm where the pacemaking activity of the heart originates from different locations within the atria. This is different from normal pacemaking activity, where the sinoatrial node (SA node) is responsible for each heartbeat and keeps a steady rate and rhythm. Causes of wandering atrial pacemaker are unclear, but there may be factors leading to its ...

  5. Multifocal atrial tachycardia; EkG STRIP SEARCH

    If the rate is more than 100, this would be considered Multifocal Atrial Tachycardia (MAT). It is possible for a wandering atrial pacemaker to occur more often in the young and among athletes. The cause usually stems from an augmented vagal tone. An increase in the vagal tone causes a slower heart rate and allows the AV node or the atria to ...

  6. Wandering Atrial Pacemaker

    An atrial arrhythmia that occurs when the natural cardiac pacemaker site shifts between the sinoatrial node (SA node), the atria, and/or the atrioventricular...

  7. Wandering Atrial Pacemaker: What Is It?

    A wandering atrial pacemaker is a rare form of a condition called arrhythmia. That's a problem with your heartbeat. It can happen anytime, even when you're sleeping. It's usually nothing to ...

  8. Wandering Atrial Pacemaker

    Rhythms are often named according to the origin of the electrical activity in the heart or the structure where the problem is occurring. Wandering Atrial Pacemaker is aptly named due to the electrical impulses causing the atrial activity are moving or wandering. These changes in the locus of stimulation affect the morphology of the P waves.

  9. Wandering Atrial Pacemaker

    This rhythm is benign. This rhythm and multifocal atrial tachycardia are similar except for heart rate. The other possible explanation is that there is significant respiratory sinus arrhythmia, with uncovering of latent foci of pacemaker activity. Usually, it is associated with underlying lung disease. In the elderly, it may be a manifestation ...

  10. Arrhythmia Recognition: The Art of Interpretation

    Practice Rhythm Strips. This ECG strip shows the classic changes of a wandering atrial pacemaker. Notice the slow, gradual transition of the P waves from upright to inverted. Longer strips show the transition occurring back and forth between the pacemakers. Notice that the QRS complexes and T waves are identical in this strip.

  11. ECG Interpretation: Blog #200

    Technically, for a rhythm to be classified as a wandering pacemaker — there should be gradual shift between at least 3 different atrial sites.Since we only see 2 different atrial sites (highlighted by RED and BLUE arrows) in Figure-2 — we would need a longer period of monitoring to prove this rhythm is a wandering pacemaker.That said — wandering pacemaker is the most logical explanation ...

  12. Pacemaker Rhythms

    Paced ECG - Electrocardiographic Features. The appearance of the ECG in a paced patient is dependent on the pacing mode used, placement of pacing leads, device pacing thresholds, and the presence of native electrical activity. Features of the paced ECG are: Pacing spikes. Vertical spikes of short duration, usually 2 ms.

  13. ECG Educator Blog : Wandering Atrial Pacemaker (WAP)

    A wandering atrial pacemaker, (WAP), is an atrial arrhythmia that occurs when the natural cardiac pacemaker site shifts between the sinoatrial node (SA node), the atria, and/or the atrioventricular node (AV node).This shifting of the pacemaker from the SA node to adjacent tissues is identifiable on ECG Lead II by morphological changes in the P-wave; sinus beats have smooth upright P waves ...

  14. Atrial Rhythms ECG Interpretation

    It is important that you measure each PR interval on the rhythm strip. Some tracings do not have the same PRi measurement from one cardiac complex to the next. Sometimes there is a prolonging pattern, sometimes not. ... The criteria is the same as Wandering Atrial Pacemaker with the only difference being the heart rate exceeds 100 bpm.

  15. Wandering atrial pacemaker

    Three or more ectopic foci within the atrial myocardium serve as the pacemaker; Rate is less than 100bpm (in contrast to MAT) Is irregularly irregular therefore sometimes confused with atrial fibrillation and sinus arrhythmia; Causes. Intrinsic cardiac or pulmonary disease; Metabolic derangements; Drug toxicity (including Digoxin) Clinical Features

  16. Wandering atrial pacemaker (WAP)

    Wandering Atrial Pacemaker (WAP) SPECIAL NOTE: Usually, you will have some NORMAL P wave configurations and two (or more) other Pwave configurations with a WAP (such as shown below). However, to call the EKG a WAP, you must see THREE different P wave configurations in your EKG Strip.Ectopic means 'other' sites (than SA node).

  17. WAP vs. MAT on ECG: What's the difference?

    If the heart rate is less than 100 BPM we call this a wandering atrial pacemaker, or WAP. If it's greater than 100 BPM we call it a multifocal atrial tachycardia, or MAT for short. Causes of WAP and MAT might include lung diseases, oxygenation deficiencies, electrolyte abnormalities, stimulant use and others (and may be a transitional rhythm ...

  18. Multifocal Atrial Tachycardia (MAT) • LITFL • ECG Library Diagnosis

    The net result is increased atrial automaticity. ECG Examples. Example 1. Multifocal atrial tachycardia: Rapid irregular rhythm > 100 bpm. At least 3 distinctive P-wave morphologies (arrows). Example 2. MAT with additional features of COPD: Rapid, irregular rhythm with multiple P-wave morphologies (best seen in the rhythm strip).

  19. Pacemaker Malfunction • LITFL • ECG Library Diagnosis

    Diagnosis of pacemaker malfunction on the ECG is very difficult and may be impossible depending on the underlying native rhythm. If pacemaker malfunction is suspected cardiology review is required to facilitate pacemaker interrogation and testing. ECG Examples. Example 1. Pacing failure: This ECG shows a ventricular paced rhythm with ...

  20. Wandering atrial pacemaker

    Description. Wandering atrial pacemaker - ECG Diagnosis • The change in P wave contour is gradual • After several cycle the pacemaker shifts back to the sinus node. • Variant of sinus arrhythmia Note: A loooooonngggg strip is needed to appreciate this rhythm #wap #Wandering #atrial #pacemaker #cardiology #diagnosis #ekg #ecg # ...

  21. Electrical Injury and Wandering Atrial Pacemaker

    Wandering atrial pacemaker (WAP) is a benign atrial arrhythmia observed in elderly patients suffering from obstructive pulmonary diseases that result from an ischemic heart. This report discusses WAP as observed in a patient who suffered an electrical injury. Keywords: wandering atrial pacemaker, voltage, electrical injury, arrhythmia, ampere.

  22. Atrial Rhythms Module

    Rhythms are often named according to the origin of the electrical activity in the heart or the structure where the problem is occurring. Wandering Atrial Pacemaker is aptly named due to the electrical impulses causing the atrial activity are moving or wandering. These changes in the locus of stimulation affect the morphology of the P waves.

  23. EkG STRIP SEARCH

    EKG Strip Search. Click the drop down list for EKG strips... then click GO! Heart Anatomy Click Here. Cardiac Blood Flow Click Here. Search for an EKG strip from a simple drop down list. Quickly find any rhythm and click go. It will pull up a page with an example strip and an easy to understand deicription. No lengthy deep learning.