This document provides an overview of cardiac pacemakers. It discusses the anatomy of the heart, conduction pathways, history of pacemakers, pacemaker components, types of pacemakers including permanent and temporary, indications for pacemakers, procedures, pacing modes, complications, nursing management, and patient education. The key points are that pacemakers are electronic devices used to treat bradyarrhythmias, they consist of a pulse generator and leads that are placed transvenously, and nursing care involves monitoring function and educating patients.

1. WELCOME ALL
GOOD MORNING

3. cardiac
PACEMAKER
PRESENTED BY
APLONI NEETHA JOSEPH

4. ANATOMY OF HEART

7. CONDUCTION PATHWAY OF HEART

8. DEFINITION
Artificial cardiac pacemaker is an electronic device used to pace
the heart when the normal conduction pathway is damaged or
diseased.

9. • Pacemaker is needed for those who with bradyarrhythmias and
tachyarrhythmias .
• In either case body doesn’t get enough blood which causes fatigue,
fainting, lightheadness, SOB, damage of vital organs and eventful
death

10. HISTORY OF
PACEMAKER

11. DR.MARK C LIDWILL
1926

14. In 1958, Arne Larsson (1915–2001)
became the first to receive an
implantable pacemaker. He had 26
devices during his life and campaigned
for other patients needing pacemakers

15. PACEMAKER COMPONENTS
Simple electric circuit consisting of:
• Battery Powered Pulse Generator
{ power source}
• Lead system
{1 or more pacing leads}
• Electrode
{that is in direct contact with heart}

16. TYPES
Permanent pacemaker – power source inside the body
Temporary pacemaker --power source outside the body
1. Transvenous
2. Epicardial
3. Transcutaneous

17. PERMANENT PACEMAKER
• The power source is implanted subcutaneously
below the clavicle,
• Usually over the pectoral muscle on the patient’s non
dominant side.
• It is attached to the pacing leads which are threaded
transvenously to the right atrium and one or both ventricles.

19. APPROACHES OF PACING
• SINGLE CHAMBER PACING: Only 1 pacing lead is implanted
either in right ventricle or right atrium
• DUAL CHAMBER PACING: In this 2 pacing leads are implanted. 1
in right atrium and 1 in right ventricle. This is most common type of
implanted pacemaker
• BI VENTRICULAR PACING: (CRT)CARDIAC
RESYNCHRONIZATION THERAPY: In this approach ,in addition
to dual chamber right heart pacing leads , a lead is advanced to the
coronary sinus for the left ventricular epicardial pacing

23. INDICATIONS
 Symptomatic bradydysarrhythmia
Heart blocks like Second degree(type2)AV block, third
degree AV block, Bundle branch block
Cardiomyopathy
Heart failure
SA node dysfunction
Tachydysarrhythmias

24. PROCEDURE

26. MODES OF PACING
SYNCHRONOUS- pacemaker only delivers a stimulus when the
hearts intrinsic pacemaker fails to function at a predetermined rate.
also called on-demand pacing
ASYNCHRONOUS PACING-
1.Fixed rate
2.Ignores the patients intrinsic rate
3.Used in emergencies when patient is in asystole
4.Sometimes used in the OR when electromagnetic interference from
electrocautery and other electrical equipment can interfere with
normal pacemaker function

28. TEMPORARY PACEMAKER
• Power source is outside the body

29. INDICATIONS
• During surgery and postoperative recovery, angioplasty
• Drug induced bradycardia (digitalis toxicity)
• Before implantation of a permanent pacemaker
• As prophylaxis after open heart surgery
• Acute MI with heart blocks
• Chest trauma
• Electrophysiological studies to evaluate patient with
bradydysarrhythmias and tachydysarrythmias

30. 1. TRANSVENOUS PACEMAKER
• Leads are threaded transvenously to the right atrium and/or
right ventricle and attached to the external power source
• Endocardial leads placed via femoral, antecubital ,Basilic,
brachial, subclavian or jugular vein.
• Usually insertion guided by fluroscopy

33. 2.EPICARDIAL PACEMAKER
• It is achieved by attaching an atrial and ventricular pacing wires
to the epicardium during heart surgery .
• The terminal wires are pulled through the skin before the chest is
closed and attached to the external power source.
• These are removed several days after surgery by gentle traction at
the skin surface with minimal bleeding risk

37. 3.TRANSCUTANEOUS PACEMAKER
• It provides adequate HR and rhythm to the patient in an
emergency situation.
• It is non invasive procedure
• used temporarily until a transvenous pacemaker can be inserted
or until more definitive therapy is available
• Most defibrillator are now equipped to perform transcutaneous
pacing

41. PACEMAKER CODING
NASPE-BPEG

43. PACEMAKER NOMENCLATURE

44. FOR AN EXAMPLE
DVI
D: BOTH ATRIUM AND VENTRICLE HAS PACING ELECTRODE
V: PACEMAKER SENSING ACTIVITY OF VENTRICLE ONLY
I :INHIBITORY FUNCTION.IT DOESNT PRODUCE AN IMPULSE WHEN PATIENTS VENTRICLE
IS ACTIVE
PACEMAKER PACES BOTH ATRIUM AND VENTRICLE WHEN THERE IS NO VENTRICULAR ACTIVITY

45. PACER SPIKES

47. PACEMAKER MALFUNCTION
• Patient with temporary or permanent pacemaker ECG will be
monitored to evaluate the status of pacemaker
Failure to sense: occurs when the pacemaker fails to recognize
patients own cardiac rhythm and it fires inappropriately .it may be due
to pacer lead damage, battery failure or dislodgement of electrode

48. Failure to capture: occurs when the electrical discharge
to the myocardium is insufficient to produce atrial or
ventricular contractions. it may be due to pacer lead
damage, battery failure or dislodgement of electrode,
electrolyte disturbance. On the ECG a pacer spike is
noted but not followed by a P wave or QRS complex

49. Failure to pace: Occurs when the pacemaker fails to initiate
an electrical stimulus when it should fire, is noted by absence
of pacer spikes on the rhythm strip

50. EXAMPLES

51. COMPLICATIONS
• Local Infection
• Bleeding
• Hematoma formation
• Phlebitis or thrombophlebitis of vein
• Pneumothorax / Hemothorax
• Embolism
• Cardiac tamponed
• Artery injury or puncture
• Perforation of atrial or ventricular septum by pacing leads

52. NURSING MANAGEMENT
PRE-OPERATIVE
Keep the patient fasting
Prepare the chest /groin area as indicated
Instruct the patient withhold antiplatelet and anti coagulant

53. POSTOPERATIVE
• Provide postoperative monitoring
• Provide analgesia and prophylactic antibiotic.
• Careful observation of insertion site
• Monitor pacemaker function with cardiac monitoring or intermittent
ECGs.
• Obtain a chest X-ray as ordered.

54. • Position for comfort.
• Document the date & time of pacemaker insertion, the model and type,
location of pulse generator and pacer settings. This information is
important for future reference.
• Immediately report signs of potential complication.
• Provide a pacemaker identification card including the manufacturer’s
name, model number, mode of operation, rate parameters, and expected
battery life. It provides a reference for the client& health care
providers.

55. PATIENT AND FAMILY TEACHING
• Maintain follow up care and do regular check on regular pacemaker
function (3-6 months)
• Report any signs of infection at incision site immediately
• Keep incision dry for 4 days after implantation
• Avoid lifting arm on pacemaker side above shoulder until approved
by doctor
• Avoid direct blows to pacemaker site

56. • Avoid strenuous exercise for 1 month
• Inform patient , the rate at which pacemaker is set
• Monitor pulse, keep a record of it
• Prescribed medications should be taken properly
• Inform doctor about trouble breathing, weight gain or get puffy legs
or ankles, or fainting, black out or getting dizzy.
• The battery of pacemaker should last 6 to 12 years or longer. When
the battery runs down, you will need surgery to replace it.

57. Modern pacemakers are not sensitive as old
• Avoid keeping cell phone/ mp3 player on the pocket over pacemaker
• Microwave ovens, TV remotes are safe to use and do not interfere with
pacemaker function.
• Modern pacemakers are MRI conditional.
• Travel without restriction is allowed .can drive. can pass through metal
detectors. If possible to avoid hand held metal detectors
• To inform about pacemaker ,if you are for any surgeries .because using
electro cautery can damage or interfere with pacemaker
• Carry Pacemaker ID or information card which has manufacturer,
model name or model number

58. CONCLUSION
• 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, failure to pace, or in-appropriate rate
• Standard ACLS protocols apply to all unstable patients with
pacemakers.