Stroke-Like Symptoms Caused By Pacemaker Malfunction

EMS is called to the residence of a 80 year old male for a possible stroke.

According to the patient’s daughter (who is a nurse) the patient had experienced weakness, slurred speech, and vomiting prior to EMS arrival.

Past medical history: Hypertension, Pacemaker

Medications: Lotensin HCT, Amlodipine

By EMS arrival the patient feels much better. He is alert and oriented.

The FAST exam (Cincinnati Stroke Scale) is negative.

Vital signs are assessed.

  • RR: 16
  • HR: 70
  • NIBP: 148/84
  • Temp: 98.5 F / 36.9 C
  • SpO2: 98% on room air

The cardiac monitor is attached.

paced 01 wmVentricular paced rhythm with a rate of 70.

The patient does not feel like he needs to go to the hospital.

A refusal is signed and the EMS crew returns to service.

The next morning a health care aid finds the patient lying on the floor. 9-1-1 is contacted and EMS returns to the residence.

The patient is found unconscious on the floor with snoring respirations.

The cardiac monitor is attached.

paced 02 wm

Ventricular asystole.

Paramedics start CPR and the patient spontaneously regains consciousness.

A rhythm change is noted on the monitor.

paced 03Ventricular paced rhyhtm with a rate of 110.

A 12-lead ECG is obtained.

paced 04 wm

Normal looking ventricular paced rhythm.

There are those who say it’s impossible to identify acute STEMI in the presence of paced rhythm but that’s not really true. You can use Sgarbossa’s criteria!

En route to the hospital several episodes of asystole are noted.

paced 05 wm

Ventricular paced rhythm with intermittent runs of asystole.

The pacing pads are placed as a precaution and the patient is delivered to the Emergency Department. Cardiology is contacted for an urgent consult.

Take-away points

Transient neurological symptoms in a pacemaker patient may be related to over-sensing or loss of capture!

Ring magnet application reverts the pacemaker to VOO (asynchronous pacing at high output).

Complaints like seizures or syncope should be considered cardiac until proven otherwise.

Pacemakers can be interrogated at the hospital to see if they are malfunctioning.

Chest x-rays can look at pacemaker leads to see if they are in place or if they are fractured.

If you’re worried enough about a patient to place them on the monitor obtain a 12-lead ECG!

Document refusals carefully!

See also

The Basics of Paced Rhythms


About author

Tom Bouthillet
Tom Bouthillet - 25 posts

Tom Bouthillet (@tbouthillet) is Editor-in-Chief of (@ECGTraining) and Fire Captain/Paramedic in South Carolina where he is the Emergency Cardiac Care Program Manager and the STEMI and CARES Site Coordinator of his fire department.

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