A pacemaker is a small device used to treat some arrhythmias.

1. WELCOME

2. PRESENTED BY
RAJEE RAVINDRAN

3. CONDUCTION SYSTEM OF HEART

4. WHAT IS PACEMAKER?
A pacemaker is a medical device that generates electrical impulses delivered by electrodes
to initiate the heart beat when hearts intrinsic electrical system cannot effectively generate
a rate adequate to support cardiac output.
NATURAL ARTIFICAL

5. Pacemakers are an electronic device used to
pace the heart when the normal conduction
pathway is damaged or diseased.

6. HISTORICAL REVIEW
Electropuncture of the heart (1828)
Electrostimulation (1820)
Albert S. Hyman first developed artificial pacemaker(1930)
Operated by a hand crank and spring
motor which turned a magneto (DC
current generator) to supply the
electricity.

7. First Working Pacemaker Implant (1960) done By Dr. Robert Rubio
Epicardial electrode was sutured to the left
ventricular surface and the pulse generator
was placed in the abdominal wall.

8. HISTORICAL REVIEW

9. HISTORICAL REVIEW

10. INDICATIONS OF PACEMAKER
♣ Symptomatic bradycardia due to sick sinus syndrome,
sinus bradycardia, complete heart block or second-degree
AV block
♣ Asymptomatic with Second- or third-degree AV block
asystole longer than 3.0 seconds or ventricular rates less
than 40 beats per minute
♣ Recurrent syncope caused by spontaneously occurring
carotid sinus stimulation and demonstrable ventricular
pauses of greater than 3 seconds
Temporary Pacemaker
Before implantation of a permanent
pacemaker.
As prophylaxis after open heart surgery.
Acute anterior MI with second degree or third
degree AV block or bundle branch block.
Acute inferior MI with symptomatic
bradycardia and AV block

11. CONTRAINDICATIONS
 Active systemic infection with bacteremia
 Severe bleeding tendencies (relative contraindication)
 Active anticoagulation therapy (relative contraindication)
 Severe lung disease and positive end-expiratory pressure ventilation (relative
contraindication for internal jugular and subclavian access)

12. COMPONENTS OF PACEMAKER
♣ Pulse generator
♣ Pacemaker electrodes
A pacemaker consists of a battery, a computerized generator and wires with sensors
at their tips (called as electrodes). The battery powers the generator and both are
surrounded by a thin metal box. The wires connect the generator to the heart.

13. TYPES OF PACEMAKER
Temporary
Pacemaker
Permanent
Pacemaker
Endocardial
Pacing
Epicardial
Pacing
Non- invasive
Pacing
Rate responsive
Pacemaker
Biventricular
Pacemaker
Dual chamber
Pacemaker
Single chamber
Pacemaker

14. Permanent Pacemaker
 For long term use
 Generator implanted in a subcutaneous pocket over the pectoral muscle on non
dominant side of the patient
 Lasts for 6 – 12 years

15. Single-chamber pacemaker
In this type, only one pacing
lead is placed into a chamber of
the heart, either the atrium or
the ventricle.
Dual-chamber pacemaker
One lead paces the atrium and
one paces the ventricle .
This type Closely resembles the
natural pacing of the heart.

16. Biventricular pacemaker
This pacemaker has three wires placed in three
chambers of the heart. One in the atrium and two
in either ventricle. It is more complicated to
implant.
Rate responsive pacemaker
It has sensors that detect changes in the
patient's physical activity and
automatically adjust the pacing rate to
fulfill the body's metabolic needs.

17. Temporary Pacemaker
 For short term use
 Located outside the body (may be tapped to skin or attached to a belt)

18. Transvenous invasive pacemaker
It consists of lead or leads that are threaded transvenously
to the right atrium and or right ventricle and attached to
external power source.
Invasive
Endocardial
Pacing

19. Transthoracic invasive pacing
It is achieved by attaching an atrial and ventricle and
attached to epicardium during heart surgery. The leads are
passed through the chest wall and attached to the external
power source.
Invasive
Epicardial
Pacing

20. Trans cutaneous pacemaker
The electrodes are incorporated into the pads and cover a
large surface area over the skin. The pads are connected
to an external pulse generator which delivers energy
through the pads to the chest wall muscles.
Non- invasive

21. 1st Position 2nd Position 3rd Position 4th Position 5th Position
Chamber
Paced
Chamber
Sensed
Response to
Sensing
Rate Modulation Multisite Pacing
A A T O O
V V I R A
D D D - V
- O O - D
A = atrium,V = ventricle, D = dual (both chambers), I = inhibited, O = none, R = rate adaptive,T = triggered
PACING CODES
The Heart Rhythm Society and the British Pacing and Electrophysiology Group (BPEG) developed a code to describe
various pacing modes.

22. ECG PACEMAKER ANALYSIS
Simple Tracing
Normal Single Chamber Pacemaker

23. ECG PACEMAKER ANALYSIS
Failure to Capture
Failure to Pace
Failure to capture means that the
ventricles fail to response to the
pacemaker impulse. On an EKG tracing,
the pacemaker spike will appear but it will
not be followed by a QRS complex.
Failure to pace occurs when the
pacemaker does not generate an electrical
impulse. On an EKG tracing, pacemaker
spikes will be missing.

24. ECG PACEMAKER ANALYSIS
Failure to sense
Failure to sense occurs when the pacemaker does not detect the patient's myocardial
depolarization. This can often be seen on an EKG tracing as a spike following a QRS
complex too early.

25. PACEMAKER COMPLICATIONS Skin erosion Pocket Hematoma
Venous thrombosis Lead perforation
TWIDDLER’S SYNDROME
Lead dislodgement

26. PACEMAKER MALFUNCTIONS
Failure to output
Failure to capture
Failure to sense
Pacemaker-mediated tachycardia
Pacemaker syndrome
Twiddler’s syndrome
Cardiac monitor pseudo malfunction
Pacemaker pseudo malfunction

27. NURSING MANAGEMENT
Preoperative care
Assess knowledge and understanding of procedure
Financial
 Explain the procedure, type, technique and cost of pacemaker.
Psychological
 Explain the Process of the pacemaker insertion.
 Reassure the patient.
Physical
 Obtain written consent from the patient and from nearest relative.
 Remove dentures, jewellery and contact lens.
 Part preparation.
 Check vital signs: temperature, BP, pulse and respiration

28. Intraoperative care
 Check serology: HIV, HbsAg, HCV and others.
 Start an IV line with 5% Dextrose solution or normal saline solution.
 Check the battery in pulse generator.
 Prepare the emergency cart, the defibrillator and jelly, and the ECG monitor.
 Set up all equipment for the insertion of the pacemaker
 Observe vital signs and observe ECG monitor carefully for arrhythmias and other complications.
NURSING MANAGEMENT

29. NURSING MANAGEMENT
Post-operative care
 Receive the patient.
 Minimize movement of the affected arm and shoulder during the initial postoperative period to reduce the risk of
dislodging.
 Assist with gentle ROM exercises at least three times daily, beginning 24 hours after pacemaker implantation.
 Monitor pacemaker function with cardiac monitoring or intermittent ECGs and chest Xray
 Monitor for complications

31. HEALTH EDUCATION
♣ Maintain follow up care to check the pacemaker site and function.
♣ Watch for signs of infection at incision site redness, swelling dressing.
♣ Keep incision dry for 1 week after implantation.
♣ Avoid lifting operative side arm above shoulder level until approved by care provider.
♣ Avoid direct blows to generators or to large magnets such as MRI scanner. These devices can reprogram a
pacemaker.

32. RESEARCH AND ABSTRACT
Topic: The effects of mobile phones on pacemaker function
Journal name: International journal of cardiology
Year of publication:2005
Author name: Izzet Tandogan et. all
Objectives: The aim of this study is to evaluate the adverse effects of mobile phones on pacemaker functions
Methods: A total of 679 patients with permanent pacemakers were enrolled in this study. The study was
performed in two steps. Pacemaker lead polarity was unipolar in the first step and bipolar in the second step.
Pacemaker sensitivity was first at nominal values, it was then reduced to the minimal value for that pacemaker
and tested again. Two mobile phones were symmetrically located on both sides of the pacemaker pocket with
the antennas being equidistant at 50, 30, 20 and 10 cm and in close contact with the pocket. The tests were
performed when both mobiles were opened, on stand-by, were receiving a call, during the call and were closed.

33. RESEARCH AND ABSTRACT
Results: Thirty-seven patients with pacemakers were adversely affected (5.5%) (33 VVI-R pacemakers were
converted to asynchronous mode, and 3 were inhibited, 1 DDD-R pacemaker developed ventricular
triggering). When the lead polarity was unipolar, the rate of adverse effect was higher when compared to the
bipolar state (4.12% and 1.40%, p<0.01). The increase in sensitivity was not an independent factor on the rate
of being affected ( p>0.05). The rate of observing an adverse effect increased as the pacemaker got older (
p<0.05).
Conclusions: Mobile phones might have adverse effects on pacemaker functions under certain conditions.
This does not result in any symptoms other than the inhibition of pacemakers, and pacemaker functions return
to normal when the mobile phones are removed away from the patient.

34. SUMMARY

35. CONCLUSION
Modern pacemakers are externally programmable and allows to select the optimal pacing
modes for individual patients.
A specific type of pacemakers called defibrillator combines pacemaker and defibrillator
functions in a single implantable device.
Others, called biventricular pacemakers have multiple electrodes stimulating differing
positions within the lower heart chambers to improve synchronization of the ventricles,
the lower chambers of the heart.

36. BIBLIOGRAPHY
Smeltzer Suzanne C, Barebrenda G, Hinkle Janice L, Cheever Kerry H. Textbook of medical surgical nursing, 12th ed.
Newdelhi: Lippincot wolter’s kluwer; p.113-114(vol-1)
Lewis Sharan mantik, Heitkemper Margaret Mclean, Shannon Ruff Dirksen,Obrien Patrical, Giddens Jean Foret, Bucher
Linda. Medical surgical nursing. 6th ed.Mosby; p.874-78
Best practices A guide to excellence in nursing care. lippincott William and wikins. P.252-53.
Pamela J Bradshaw, Paul Stobie, Matthew W Knuiman, Thomas G Briffa, Michael S T Hobbs. Trends in the incidence and
prevalence of cardiac pacemaker insertions in an ageing population. 2014; 1(1)
www.nhlbi.nih.gov/health/healthtopics/topics/pace/howdoes
https://www.internationaljournalofcardiology.com/article/S01675273(04)00693-X/abstract
https://emedicine.medscape.com/article/1839735-technique#c2

37. ANY DOUBTS

38. EVALUATION