Pacemakers and their problems
Sept 2013
Indications
•Symptomatic heart block
•Symptomatic sinus brady
•AF with symptomatic brady
Also:
•Cardiac Resynchronization ...
Device =
Mode =
Normal: atria and ventricle paced
Normal: ventricle paced
WhoCares?
http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th-
september-2013_18.html
http://lifeinthefastlane.com/ecg-library/pace...
https://gmep.org/media
http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th-
september-2013_18.html
Problems
Early:
•Infection
•Bleeding
•Lead misplacement
•Pacemaker syndrome
(poor coordination)
•thrombosis
Late:
•Battery...
Pacemaker mediated tachy [=AVRT]
http://lifeinthefastlane.com/ecg-library/pacemaker-malfunction/
Runaway pacemaker
Magnet Mode
Lead Fracture
Falls & Blackouts
April 2012
Falls and blackouts
Acknowledgements/images
•Life in the fast lane
•Sonocloud.org
•Andy Buck
•the wonders ofYouTube and Wi...
Falls and Blackouts
Blackout/Syncope
Falls
http://www.youtube.com/watch?v=DU_i0ZzIV5U
Blackouts/Syncope
Serious Benign
•Cardiac
•HOCM
•Brugada
•ARVH
•QT
•AS
•Arrhythmias...
•PE
•Aortic
•Ectopic
•SAH
•Seizure
...
Cardiac
•sudden
•palpitations
•chest pain
•witnessed
•? LOC
•? murmur
•vital signs (RR!)
•cognition
•neuro
ECG
? Blood Sug...
HOCM
HOCM
Brugada
•Likely common cause of SCD
•ICD only treatment
•presence of symptoms is important
•Quoted 10% mortality a year if...
RBBB Brugada Brugada
Orthodromic Antidromic
Normal AF WPW AF
Long QT
•Just use the calculated QTc
•>500ms before badness happens
Causes
•Syndrome - rare
•Low electrolytes
•All the dru...
CHESS
San Fran/CHESS
The rule performed with a sensitivity of 90% (44/49 outcomes; 95%
confidence interval [CI] 79% to 96%) and a...
Falls in the elderly
Serious Benign
•Everything... •Nothing...
ACS
•Common
•Usually with an associated “anginal equivalent” (lethargy,
diaphoresis, shortness of breath)
•If isolated bla...
Found on the floor...
•Rhabdo
•Hypothermia
•Fractures
If they’re now back to baseline?
PMID: 17200478
Risk Assessment
Timed up and go [>20 secs abnormal]
http://www.youtube.com/watch?v=dsTfqk9ZTiw
As yet...
There is no good, reliable test
•Risk assessment
•Gait assessment
•Have they fallen in the past year
•Falls clin...
Driving regulations?
Provoked:
MMUH reg teaching: pacemakers falls blackouts
MMUH reg teaching: pacemakers falls blackouts
MMUH reg teaching: pacemakers falls blackouts
MMUH reg teaching: pacemakers falls blackouts
MMUH reg teaching: pacemakers falls blackouts
MMUH reg teaching: pacemakers falls blackouts
MMUH reg teaching: pacemakers falls blackouts
MMUH reg teaching: pacemakers falls blackouts
MMUH reg teaching: pacemakers falls blackouts
MMUH reg teaching: pacemakers falls blackouts
MMUH reg teaching: pacemakers falls blackouts
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MMUH reg teaching: pacemakers falls blackouts

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slideset from this talk http://emergencymedicineireland.com/2012/08/blackouts-and-syncope/

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MMUH reg teaching: pacemakers falls blackouts

  1. 1. Pacemakers and their problems Sept 2013
  2. 2. Indications •Symptomatic heart block •Symptomatic sinus brady •AF with symptomatic brady Also: •Cardiac Resynchronization Therapy •Defibs
  3. 3. Device = Mode =
  4. 4. Normal: atria and ventricle paced
  5. 5. Normal: ventricle paced
  6. 6. WhoCares?
  7. 7. http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th- september-2013_18.html http://lifeinthefastlane.com/ecg-library/pacemaker/
  8. 8. https://gmep.org/media
  9. 9. http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th- september-2013_18.html
  10. 10. Problems Early: •Infection •Bleeding •Lead misplacement •Pacemaker syndrome (poor coordination) •thrombosis Late: •Battery •failure •runaway pacemaker •Lead Fracture •Skin Erosion •‘Twiddler’s syndrome’ •thrombosis (usually chronic and not a problem) General: •Mis-sensing •Pacemaker mediated tachy
  11. 11. Pacemaker mediated tachy [=AVRT] http://lifeinthefastlane.com/ecg-library/pacemaker-malfunction/
  12. 12. Runaway pacemaker
  13. 13. Magnet Mode
  14. 14. Lead Fracture
  15. 15. Falls & Blackouts April 2012
  16. 16. Falls and blackouts Acknowledgements/images •Life in the fast lane •Sonocloud.org •Andy Buck •the wonders ofYouTube and Wiki •Amal Mattu
  17. 17. Falls and Blackouts Blackout/Syncope Falls http://www.youtube.com/watch?v=DU_i0ZzIV5U
  18. 18. Blackouts/Syncope Serious Benign •Cardiac •HOCM •Brugada •ARVH •QT •AS •Arrhythmias... •PE •Aortic •Ectopic •SAH •Seizure •?TIA •Neurocardiogenic/vasovagal/faint •Meds •Micturition/Cough syncope •Necktie/Shaving syncope
  19. 19. Cardiac •sudden •palpitations •chest pain •witnessed •? LOC •? murmur •vital signs (RR!) •cognition •neuro ECG ? Blood Sugar History Exam
  20. 20. HOCM
  21. 21. HOCM
  22. 22. Brugada •Likely common cause of SCD •ICD only treatment •presence of symptoms is important •Quoted 10% mortality a year if untreated (though recent evidence questions this...) PMID 20100972
  23. 23. RBBB Brugada Brugada
  24. 24. Orthodromic Antidromic
  25. 25. Normal AF WPW AF
  26. 26. Long QT •Just use the calculated QTc •>500ms before badness happens Causes •Syndrome - rare •Low electrolytes •All the drugs in the world...
  27. 27. CHESS
  28. 28. San Fran/CHESS The rule performed with a sensitivity of 90% (44/49 outcomes; 95% confidence interval [CI] 79% to 96%) and a specificity of 33% (95% CI 32% to 34%). Rule performance to predict serious outcomes was sensitivity 74% (95% CI 61% to 84%), specificity 57% (95% CI 53% to 61%) The rule was 98% sensitive (95% confidence interval [CI] 89% to 100%) and 56% specific (95% CI 52% to 60%) to predict these events.
  29. 29. Falls in the elderly Serious Benign •Everything... •Nothing...
  30. 30. ACS •Common •Usually with an associated “anginal equivalent” (lethargy, diaphoresis, shortness of breath) •If isolated blackout with no symptoms prior or after then unlikely (quoted <1% pick up rate for trops in syncope) •Difficulty given baseline ECG changes and renal function
  31. 31. Found on the floor... •Rhabdo •Hypothermia •Fractures
  32. 32. If they’re now back to baseline? PMID: 17200478
  33. 33. Risk Assessment Timed up and go [>20 secs abnormal] http://www.youtube.com/watch?v=dsTfqk9ZTiw
  34. 34. As yet... There is no good, reliable test •Risk assessment •Gait assessment •Have they fallen in the past year •Falls clinic/assessment
  35. 35. Driving regulations? Provoked:

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