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Pacemaker for beginners. KITA yosuke Iizuka Hospital. Objectives. Review basic pacemaker terminology and function Discuss diagnosis and management of pacemaker emergencies . Historical Perspective. Electrical cardiac pacing for the management of brady-arrhythmias was first described in 1952

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pacemaker for beginners

Pacemaker for beginners

KITA yosuke

Iizuka Hospital

  • Review basic pacemaker terminology and function
  • Discuss diagnosis and management of pacemaker emergencies
historical perspective
Historical Perspective
  • Electrical cardiac pacing for the management of brady-arrhythmias was first described in 1952
  • Permanent transvenous pacing devices were first introduced in the early 1960’s
pacemaker components
Pacemaker Components
  • Pulse Generator
  • Electronic Circuitry
  • Lead system
pulse generator
Pulse Generator
  • Lithium-iodine cell is the current standard battery
  • Advantages:
    • Long life – 4 to 10 years
    • Output voltage decreases gradually with time making sudden battery failure unlikely
electronic circuitry
Electronic Circuitry
  • Determines the function of the pacemaker itself
  • Utilizes a standard nomenclature for describing pacemakers
lead systems
Lead Systems
  • Endocardial leads which are inserted using a subclavian vein approach
  • Actively fixed to the endocardium using screws or tines
  • Unipolar or bipolar leads
electrocardiogram during cardiac pacing
Electrocardiogram During Cardiac Pacing
  • Pacemaker has two main functions:
    • Sense intrinsic cardiac electrical activity
    • Electrically stimulate the heart
  • VVI- senses intrinsic cardiac activity in the ventricle and when a preset interval of time with no ventricular activity occurs it depolarizes the right ventricle causing ventricular contraction
  • Dual chamber pacer is more complicated because the pacer has the ability to both sense and pace either the atrium or the ventricle
  • Possible to have only atrial, only ventricular or both atrial and ventricular pacing
  • DDD pacer is a common example of this

Atrial Spike

Ventricular Spike

magnet placement
Magnet Placement
  • The EKG technician should perform a 12 lead cardiogram and then a rhythm strip with a magnet over the pacer
  • Often a very poorly understood concept by the non-cardiologist
  • Does not inactivate the pacer as is commonly believed
  • Activate a lead switch present in the pacemaker which converts the pacer to a asynchronous or fixed-rate pacing mode
  • Inhibits the sensing function of a pacemaker
class i indications for permanent pacing
Class I Indications For Permanent Pacing
  • Third degree AV block associated with:
    • Symptomatic bradycardia
    • Symptomatic bradycardia secondary to drugs required for dysrhythmia management
    • Asystole > 3 seconds or escape rate < 40
    • After catheter ablation of the AV node
    • Post-op AV block not expected to resolve
    • Neuromuscular disease with AV block
  • Symptomatic bradycardia from second degree AV block
  • Bifascicular or trifascicular block with intermittent third degree or type II second degree block
  • Sinus node dysfunction with symptomatic bradycardia
  • Recurrent syncope caused by carotid sinus stimulation
  • Post myocardial infarction with any of:
    • Persistent second degree AV block with bilateral bundle branch block or third degree AV block
    • Transient second or third degree AV block and bundle branch block
    • Symptomatic, persistent second or third degree AV block
  • Pacemaker insertion is a surgical procedure:
    • 1% risk for bacteremia
    • 2% risk for wound or pocket infection
  • Usually occur soon after pacer insertion
  • Presence of a foreign body complicates management
  • Cellulitis or pocket infection:
    • Tenderness and redness over the pacemaker itself
    • Avoid performing a needle aspiration – damage the pacer
  • Bacteremia: Staphylococcus
    • aureus and Staphylococcus epi 60-70% of the time
    • Empiric antibiotics should include vancomycin pending culture
  • Consult the pacemaker physician
  • Draw blood cultures
  • Give appropriate antibiotics
  • Frequently the pacer and lead system need to be removed
case 1
Case 1
  • 67 year old male presents to the emergency room 12 hours after insertion of a pacemaker complaining of left sided chest pain and shortness of breath
  • PR96, RR 33, BP 125/85, Oxygen saturation 88% RA
  • CXR as shown
  • Occurs during cannulation of the subclavian vien
  • Incidence - ?? Cardiologist dependent
  • Treatment:
    • Asymptomatic or small – observation
    • Symptomatic or large – tube thoracostomy
  • Notify the pacemaker physician
case 2
Case 2
  • 72 year old male presents to the emergency room after a fall, tripped over a bath mat, no LOC
  • Shortened and rotated left leg
  • Past history – pacemaker, hypertension
  • Nurse does an routine pre-op CXR and EKG
septal perforation
Septal Perforation
  • Usually identified at the time of pacer insertion but leads can displace after insertion
  • Can occur with transvenous pacer insertion
  • Keys diagnosis are a RBBB pattern on EKG and a pacer lead displaced to the apex of the heart on CXR
septal perforation31
Septal Perforation
  • Management:
    • Notify the pacer service
    • Pacer wire has to be removed but not emergently
    • Small VSD which heals spontaneously
  • Pacemakers are becoming more common everyday
  • We need to understand basic pacing terminology and modes to treat patients effectively.
  • Most pacer malfunctions are due to failure to sense, failure to capture, over-sensing, or in-appropriate rate
  • Standard ACLS protocols apply to all unstable patients with pacemakers.