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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

  • 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
  • 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
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
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
case 3
Case 3
  • 54 yr old male presents to the ER with palpitations and feeling light headed.
  • No chest pain/SOB
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 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
  • Placed in patient with
    • class IV chf
    • Ventricular arrthymias
    • HOCUM
icd s1
  • 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
  • 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