Junctional rhythm

A 60 years old male came with  complaints of giddiness along with dyspnoea on exertion since last 10 days.  During evaluation patient pulse was 38 beats per minute  Patient ECG is shown below.

ECG (Click on the image to enlarge it)

ECG  is showing bradycardia with heart rate around 38 beats per minute, QRS complex of RBBB morphology,  QT interval 520 msec, QTc was 416 msec, few P waves are seen which appears to merged into QRS complex in lead II,III,avF and they were inverted in nature, suggestive of rhythm originating from junction of atrium and ventricle below the HIS bundle or infra his in origin  impulse (presence of broad complex RBBB type QRS) Final diagnosis was severe sinus node dysfunction with junctional bradycardia.

On blood investigation patient serum potassium was 5.2 meq/dl, while serum creatinine was 2.3 mg/dl. Patient was started on anti hyperkalemia  measure in the form of calcium gluconate along with insulin glucose drip but patient bradycardia did not improved.  Decision was taken for pacemaker implantation. Permanent pacemaker implantation was done with AAI mode and later was discharged in stable condition. 

Thank you

Praveen Gupta