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Craig hore on emergency pacing


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Craig hore on emergency pacing

  1. 1. Asystole: a true story. Craig Hore
  2. 2. And I don’t mean this one…
  3. 3. Asystole is the end  60 year old man ?previously well  Presented to regional hospital ED with     syncope Asystolic arrest soon after arrival Intubated CPR and adrenaline ~ 20 mins Called for senior advice (no ED SS)
  4. 4. “Should we call it?”
  5. 5. “Let me have a quick look…”  Patient is as described  ECG rhythm strip:
  6. 6. “Surely we can call it now?” What would you do?
  7. 7. Clinical examination  Patient looks surprisingly pink for at least 20 mins asystole  Confirm no peripheral pulses but palpable “pulses” with CPR  “Gut feeling” is hmmmm…….  What’s that rule about asystole?
  8. 8. Is it really asystole?  Check other leads (I,III, V) – no obvious difference  Closer look at lead II – are those small bumps?  Rhythm strip with increased amplitude:
  9. 9. “What now then?” This calls for something completely different….
  10. 10. Wasn’t thinking of this. But…?
  11. 11. Transcutaneous pacing
  12. 12. Transcutaneous pacing  “Older style” TCPM (Lifepak)  Rate set at 70bpm  Amplitude increased by 20 mA increments  Capture at 120 mA  Good pulses and SBP 130mmHg!
  13. 13. Rembrandt van Rijn “The Raising of Lazarus” Los Angeles County Museum of Art, Los Angeles
  14. 14. (WTF!)V Rembrandt van Rijn “The Raising of Lazarus” Los Angeles County Museum of Art, Los Angeles
  15. 15. The Raising of Lazarus…..  Patient started to move!.....  …opened eyes!!......  ..responded to simple instructions!!!  Transcutaneous pacing did not appear to be causing him to much discomfort  What now?
  16. 16. Temporary pacing wire  Insertion of temporary transvenous pacing wire in ED (RIJV; balloon flotation)
  17. 17. Temporary transvenous pacing  How do I know it’s in the correct position?  Length of insertion  ECG electrode  Ectopics  CXR / bedside imaging
  18. 18. Temporary transvenous pacing  What settings? - demand? - rate? - sensitivity? - output?
  19. 19. Settings  Capture threshold - the minimum electricity output (mA) required to pace the heart (capture)  Asynchronous – paces at a fixed rate, ignoring any of the patient’s intrinsic activity  Demand - paces only if the intrinsic heart rate gets lower than the set rate. This is the usual setting.  Sensitivity – the sensitivity of the pacemaker to the patient’s intrinsic activity. When an intrinsic beat is “sensed’ (sensing light), this “inhibits” the pacemaker from firing
  20. 20. Settings  Setting sensitivity – turn the output to 0 (prevent discharge); set rate below intrinsic rate; reduce sensitivity (increase amplitude) until no sensing of intrinsic activity (sensing threshold); set at ~ half the amplitude of this threshold.  Setting output – turn output to 0 and set rate at 10-15 bpm higher than intrinsic rate; increase output until capture occurs (capture threshold); set at 2-3 times higher than this threshold.
  21. 21. Eventual outcome  Extubated inED  Admitted to CICU  History of syncope over several months – neurological work-up was normal!  Probable sick sinus syndrome  Referred to Metropolitan hospital for permanent pacemaker  Full neurological recovery and return to usual independent activities
  22. 22. Summary  Don’t ignore those gut instincts  The old rule of thumb: a rhythm disturbance with haemodynamic compromise needs electricity  Temporary pacing can save lives  Transcutaneous pacing is getting better and easier  Temporary transvenous pacemaker insertion is getting better and easier
  23. 23. GiottoThe Arena Chapel Frescoes: The Raising of Lazarus
  24. 24. GiottoThe Arena Chapel Frescoes: The Raising of Lazarus “It’s a miracle!! The Haematologist was right!”