Pacemaker emergencies
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Pacemaker Emergencies. Arun Abbi MD Jan 21, 2010. Overview. Initial approach Pocket Complications Acute complications with placement Nonarrythmic complications Pacemaker function issues. Initial Approach. ABC’s - make sure your patient is stable and on a monitor Pacemaker Information

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Pacemaker emergencies

Pacemaker Emergencies

Arun Abbi MD

Jan 21, 2010


Overview

Overview

  • Initial approach

  • Pocket Complications

  • Acute complications with placement

  • Nonarrythmic complications

  • Pacemaker function issues


Initial approach

Initial Approach

  • ABC’s

    • - make sure your patient is stable and on a monitor

  • Pacemaker Information

    • pacemaker type, model, number and manufacturer

    • Patient will often have a card with the info


Initial approach1

Initial Approach

  • EKG

    • Should be a LBBB pattern for the QRS

  • Meds

    • Cardiac meds, anti seizure meds (dilantin)

  • Lytes

    • Check K+,Mg+,Ca+


Initial approach2

Initial Approach

  • If patient is stable and is complaining of palpitations, near syncope, light headedness

    • Get the pacemaker nurse to interrogate the pacemaker


Pocket complications

Pocket Complications

  • Hematomas

    • Occur after implantation-venous or arterial bleeder (check for anticoagulation)

    • If the size of your palm - needs surgery

  • Infection

    • Acute infection - staph aureus

    • Chronic/late infection - staph epidermidis


Case 1

Case 1

  • 76 yr old male presents with chest pain for 2 days

  • Pain worse with lying down and better with sitting up

  • No diaphoresis/orthopnea/SOB

  • Pt had a pacemaker inserted 3 weeks earlier

  • V/S and physical were normal


Pacemaker emergencies

EKG


Management

Management?

  • What do you want to do?

  • Any concerns?


Complications with placement

Complications with Placement

  • Pneumothorax/hemothorax

    • Typically present in the first 48 hrs.

    • Treat as most pneumothoraces

  • DVT

    • Upper extremity DVT’s can occur soon after placement or in a delayed fashion. Secondary to endothelial disruption

  • Infection

    • Can get endocarditis (right sided)

    • Can present with chronic infection - wasting/malaise/thromocytopenia/anemia


Complications with placement1

Complications with Placement

  • Acute dislodgement

    • Patient may have an ASD/VSD and pacemaker lead may migrate across the heart or may migrate into a coronary sinus.

  • Myocardial Perforation

    • Can present as acute pericarditis

    • Can present with hiccups secondary to diaphragmatic innervation


Failure to pace

Failure to Pace

  • 1.Oversensing

    • Secondary to the pacemaker sensing P or T waves of muscle fasciculations

      • Careful with succinylcholine

    • Higher incidence with unipolar sensing (VVI) as the antennae is larger

    • Treatment - reduce the sensitivity


Oversensing

Oversensing


Oversensing1

Oversensing


Failure to pace1

Failure to Pace

  • 2. Failure to capture

    • When the impulse is insufficient to cause myocardial depolarization

    • Causes

      • Lead Fracture

      • Battery failure

      • Pacemaker failure

      • Local inflammatory response post insertion

      • Electrolyte imbalance leading to prolonged Q-T

      • Medications


Case 2

Case 2.

  • 62 yr old female presents to emergency with increasing lethargy and confusion

  • Pt has had a few falls

  • PMHx

    • Pt has hx of complete heart block and has a VVI pacemaker


Pacemaker emergencies

EKG


Failure to pace2

Failure to Pace

  • Management

    • 1. Make sure pacemaker rate is faster than intrinsic heart rate (to see if it paces)

      • Will see change in QRS morphology (LBBB)

    • 2. CXR (look for lead fracture)

    • 3. Check Lytes

    • 4. Check Meds


Cxr with lead fracture

CXR with Lead fracture


Case 3

Case 3

  • 54 yr old male presents to the ER with palpitations and feeling light headed.

  • No chest pain/SOB


Pacemaker emergencies

EKG


Failure to sense

Failure to Sense

  • When the pacemaker fails to detect native cardiac activity

    • Secondary to ischemia, infarct, pvc’s

    • Lead dislodgement/fracture


Failure to sense1

Failure to Sense

  • Management

    • CXR

    • Lytes

    • Meds

    • Will need pacemaker interrogated for malfunction


Pacemaker mediated tachycardia

Pacemaker Mediated Tachycardia

  • 1. Endless Loop Tachycardia

    • Re-entry dysrhythmia that occurs with dual chamber pacemakers

    • PVC - initiating factor

    • Retrograde P-waves that are sensed by the atrial lead - leading to subsequent ventricular paced beat

    • Treatment - apply magnet over the patient’s pacemaker to break the cycle

    • Have pacemaker nurse reset parameters of pacemaker


Pacemaker mediated tachycardia1

Pacemaker Mediated Tachycardia


Pacemaker mediated tachycardia2

Pacemaker Mediated Tachycardia

  • 2. Tracking of Native Atrial Tachyarrythmia

    • Atrial Flutter/Atrial Fib.

  • Management

    • Cardiovert the patient if < 48 hrs or pt is therapeutically anticoagulated

    • Slow the ventricular response rate


Pacemaker syndrome

Pacemaker Syndrome

  • Loss of A-V synchrony caused by suboptimal pacing modes

    • Atrial Lead failure

    • Single chamber Pacemakers

  • Treatment

    • Interrogate/correct pacemaker

    • Check for lead # in the atrium


Runaway pacemaker

Runaway Pacemaker

  • When you see rapid tachycardia > 300 beats/minute

  • True emergency -may lead to VT/VF

  • Due to pacemaker damage

  • Management

    • Place the magnet over the patient’s pacemaker

    • It will default to asynch mode at a rate of 70


Pacemaker and mi s

Pacemaker and MI’s

  • Treat as per patient with LBBB

    • Concordant ST changes > 1mm

    • ST depression > 1mm in the anterior leads V1 - V3

    • Discordant ST changes > 5 mm in the anterior leads

  • Can also slow the pacemaker rate down and see what the underlying ST changes are (would need pacemaker nurse to come in

  • If concerned - refractory pain not amenable to medical Tx - send to the cath lab.


Icd s

ICD’s

  • Placed in patient with

    • class IV chf

    • Ventricular arrthymias

    • HOCUM


Icd s1

ICD’s

  • Pt’s with V-fib

    • ICD will shock immediately and every 5-10 seconds thereafter

    • After 15 shocks it will time out for 10 - 15minutes

  • Pt’s with V-tach

    • ICD will try to overdrive pace for 15-20 seconds before initiating a shock

    • It will give repeated shocks and then time out after 15-20 shocks to prevent battery fatigue


Icd s2

ICD’s

  • If the patient has had ICD shocks; the patient should be seen by cardiology/ICD nurse to have the device interrogated

  • Check EKG - ischemia

  • Check lytes


Refractory v tach

Refractory V-tach

  • If wanting to turn off ICD – place magnet over the ICD

  • Place defib pads Anterior – Posterior

  • Shock as per normal


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