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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
   pacemaker type, model, number and
    manufacturer
   Patient will often have a card with the info
Initial Approach

EKG
   Should be a LBBB pattern for the QRS
Meds
   Cardiac meds, anti seizure meds (dilantin)
Lytes
   Check K+,Mg+,Ca+
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

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

 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
EKG
Management?

What do you want to do?
Any concerns?
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 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

 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
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.

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
EKG
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
Case 3

54 yr old male presents to the ER with
 palpitations and feeling light headed.
No chest pain/SOB
EKG
Failure to Sense

When the pacemaker fails to detect
 native cardiac activity
   Secondary to ischemia, infarct, pvc’s
   Lead dislodgement/fracture
Failure to Sense

Management
   CXR
   Lytes
   Meds
   Will need pacemaker interrogated for
    malfunction
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 Tachycardia
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

 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

 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
 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’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’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

If wanting to turn off ICD – place magnet
 over the ICD
Place defib pads Anterior – Posterior
Shock as per normal

								
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