Pacemaker Emergencies

Arun Abbi MDJan 21, 2010

Overview

Initial approachPocket ComplicationsAcute complications with placementNonarrythmic complicationsPacemaker function issues

Initial Approach

ABC’s - make sure your patient is stable and on a

monitorPacemaker 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 fallsPMHx

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 - ischemiaCheck lytes

Refractory V-tach

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

Place defib pads Anterior – PosteriorShock as per normal