Pacemakers & Pacing in the Pacemakers & Pacing in the EDED

Albury Wodonga Education Program 2014Albury Wodonga Education Program 2014

What’s wrong here?What’s wrong here?

Twiddlers syndromeTwiddlers syndromefollow the link to follow the link to

read moreread moreTwiddler syndromeTwiddler syndrome

Ventricular Ventricular ElectrophysiologyElectrophysiology

Pacemaker cellsPacemaker cells

MyocytesMyocytes

Conduction pathwaysConduction pathways

Ventricular Depolarisation from N Engl J Med Ventricular Depolarisation from N Engl J Med 2006;355:288-942006;355:288-94

Figure 3. Modulation of cardiac electrical activity by activation of ClC-2 channels in cardiac Figure 3. Modulation of cardiac electrical activity by activation of ClC-2 channels in cardiac pacemaker cells and myocytes Changes in action potentials (top panels) and membrane currents pacemaker cells and myocytes Changes in action potentials (top panels) and membrane currents

(bottom panels) of cardiac pacemaker cells (A), or atrial and ventricular myocytes(bottom panels) of cardiac pacemaker cells (A), or atrial and ventricular myocytes

Duan D J Physiol 2009;587:2163-2177Duan D J Physiol 2009;587:2163-2177

©2009 by The Physiological Society©2009 by The Physiological Society

• Slide showing spontaneous decay of membrane potential Slide showing spontaneous decay of membrane potential causing phase 0 of pacemaker cellscausing phase 0 of pacemaker cells

• note: myocytes also decay but less quickly hence slower note: myocytes also decay but less quickly hence slower intrinsic ratesintrinsic rates

Why do we need to Why do we need to pace?pace?

Sinuatrial pause/arrestSinuatrial pause/arrest

Atrial FibrillationAtrial Fibrillation

AV block - high degrees which are newAV block - high degrees which are new

Neurally mediated syncopeNeurally mediated syncope

Heart failure - severe cardiomyopathyHeart failure - severe cardiomyopathy

Cardiac Resynchronisation Therapy -CRTCardiac Resynchronisation Therapy -CRT

Overdrive pacingOverdrive pacing

Permanent PacemakersPermanent Pacemakers

Permanent PacemakersPermanent Pacemakers

only way of knowing only way of knowing how it operates is by how it operates is by getting the details getting the details from the patientfrom the patient

can only interrogate can only interrogate the device if you the device if you know what type it isknow what type it is

Pacing ModesPacing Modes

Chamber pacedChamber paced

OO-none, -none, AA-atrial, -atrial, VV-ventricular, -ventricular, DD-dual-dual

Chamber sensedChamber sensed

OO-none, -none, AA-atrial, -atrial, VV-ventricular, -ventricular, DD-dual-dual

Response to sensingResponse to sensing

OO-none, -none, TT-triggered, -triggered, II-inhibited, -inhibited, DD-dual-dual

Magnets and Magnets and pacemakerspacemakers

All pacemakers respond to a magnet by All pacemakers respond to a magnet by switching to an asynchronous pacing mode at a switching to an asynchronous pacing mode at a programmed atrioventricular (AV) delay and a programmed atrioventricular (AV) delay and a fixed magnet rate depending on the fixed magnet rate depending on the manufacturer, device model, and the status of manufacturer, device model, and the status of the battery. the battery.

The programmed mode DDD switches to DOO, The programmed mode DDD switches to DOO, VVI switches to VOO, and AAI switches to AOOVVI switches to VOO, and AAI switches to AOO

Why pace in EDWhy pace in ED

BradycardiaBradycardia

Sinuatrial diseaseSinuatrial disease

3rd degree AV block3rd degree AV block

type 2, second degree blocktype 2, second degree block

myocardial infarction causing significant AV myocardial infarction causing significant AV blockblock

Why pace in the EDWhy pace in the ED

Profound rhythm disturbance causing Profound rhythm disturbance causing haemodynamic compromisehaemodynamic compromise

Slow rates can be tolerated if BP/GCS normalSlow rates can be tolerated if BP/GCS normal

Failure of chronotropic pharmacotherapies - Failure of chronotropic pharmacotherapies - isoprenaline, adrenaline (atropine is a isoprenaline, adrenaline (atropine is a temporary measure)temporary measure)

When do we pace in ED?When do we pace in ED?

The decision to institute pacing in the ED The decision to institute pacing in the ED should be taken by senior staff or in discussion should be taken by senior staff or in discussion with a tertiary centre in Melbournewith a tertiary centre in Melbourne

Pacing is not technically difficultPacing is not technically difficult

The decision to pace is the difficult partThe decision to pace is the difficult part

How can we pace?How can we pace?

TranscutaneousTranscutaneous

TransvenousTransvenous

Transcutaneous pacingTranscutaneous pacing

ConsentConsent

Clean and dryClean and dry

optimise contactoptimise contact

Analgesia & SedationAnalgesia & Sedation

infusions of opiate infusions of opiate and benzodiazepine to and benzodiazepine to relieve pain/distress relieve pain/distress but maintain airwaybut maintain airway

Transcutaneous pacingTranscutaneous pacing

ModeMode

Fixed or DemandFixed or Demand

Demand avoids R on TDemand avoids R on T

EnergyEnergy

as little as required +10mVas little as required +10mV

RateRate

60-70bpm60-70bpm

enough to maintain enough to maintain haemodynamicshaemodynamics

Transcutaneous PacingTranscutaneous Pacing

Confirm CaptureConfirm Capture

ElectricalElectrical

MechanicalMechanical

check pulse or arterial wave formcheck pulse or arterial wave form

TeTextxt

Pacing - how to make the Phillips defib. Pacing - how to make the Phillips defib. work.work.

Transvenous pacingTransvenous pacing

sterile techniquesterile technique

multiple routesmultiple routes

best to avoid L sub best to avoid L sub clavian as this clavian as this route most route most commonly used for commonly used for permanent permanent pacemakerpacemaker

Transvenous pacingTransvenous pacing

Start 25mA - should be Start 25mA - should be able to reduce to 5mAable to reduce to 5mA

Rate 60-70bpmRate 60-70bpm

adjust sensitivity settings adjust sensitivity settings to consistently detect to consistently detect native R wavesnative R waves

see:see:sensitivity settingsensitivity setting for a recommendation for a recommendation on how to do thison how to do this

Transvenous pacingTransvenous pacing

InvasiveInvasive

Less energy requiredLess energy required

safer for transfersafer for transfer

ECG showing atrial ECG showing atrial pacingpacing

How to tell if the How to tell if the pacemaker is also a pacemaker is also a defibrillator.defibrillator.

Shock coilsShock coils

Shock Shock coilscoils

ICD - Internal Cardioverting ICD - Internal Cardioverting DefibrillatorDefibrillator

What can go wrong?What can go wrong?

Failure to captureFailure to capture

HiccupsHiccups

PainPain

BleedingBleeding

InfectionInfection

LinksLinks

http://lifeinthefastlane.com/education/ccc/pacemakerhttp://lifeinthefastlane.com/education/ccc/pacemakers/s/

http://lifeinthefastlane.com/education/ccc/temporary-http://lifeinthefastlane.com/education/ccc/temporary-pacemaker-troubleshooting/pacemaker-troubleshooting/

http://radiopaedia.org/articles/cardiac-pacemakershttp://radiopaedia.org/articles/cardiac-pacemakers

http://www.cardiacengineering.com/pacemakers-wallhttp://www.cardiacengineering.com/pacemakers-wallace.pdface.pdf

http://www.modernmedicine.com/modern-medicine/http://www.modernmedicine.com/modern-medicine/news/temporary-pacemakersnews/temporary-pacemakers