1st Year MSc Nursing Medical Surgical Nursing MIMS CON

1. Prepared by
Ms Theertha P Krishna
1st Year MSc Nursing
MIMSCON
pacemaker

2. Definition
• An electronic device used to pace the heart
when the normal conduction pathway is
damaged or diseased.
• A cardiac pacemaker is an electronic device,
that delivers, direct electrical stimulation to
stimulate the myocardium to depolarize,
initiating a mechanical contraction.

3. Function of pacemaker
• Pacing function
• Sensing function
• Capture function

4. Pacing function:
• It is the ability of the pacemaker to stimulate
either the atrium, Ventricle, or both chambers
in sequence and initiate electrical
depolarization and cardiac contraction.
• Atrial pacing
• Ventricular pacing
• Atrio-ventricular pacing.

5. • SENSING FUNCTION:
• Cardiac pacemaker have the ability to see
intrinsic cardiac Activity when it occurs.
• CAPTURE FUNCTION:
• The ability to generate a response from the
heart [contraction] after electrical stimulation
is referred as capture.

6. Types of pacemaker
• Permanent pacemaker
• Temporary pacemaker
 Transvenous pacing
 Epicardial pacing
 Transcutaneous pacing

7. Permanent pacemaker
• It is implanted totally with in the body. The
power source is implanted subcutaneously
usually over the pectoral muscle on the
patients non dominant side. The pacing leads
are threaded transvenously to the chamber to
be paced.

8. Pace maker modes
• Fixed rate: fire constantly at a preset rate
with out regard to the electrical activity of the
patient’s heart
• Demand: it detects the hearts electrical
activity. Fires only when the electrical activity
of heart drops below the pre set rate.

9. Temporary pacemaker
It has the power source outside the body
• Types:
• Transvenous pacemaker
Leads are threaded transvenously to the chambers
and attached to the power source
• Epicardial pacing
The pacing leads are attached to the epicardium
during heart surgery
• Transcutaneous pacemaker
Noninvasive, power source is attached to large
electrodes placed over the anterior and posterior chest

10. Trans venous pacing

11. METHODS OF PLACEMENT OF A
TEMPORARY PACEMAKER:
• Transvenous pacemakers:
• Inserted transvenously( usually subclavian,
internal jugular, antecubital or femoral), into
the right ventricle( or right atrium) and right
ventricle for dualchamber pacing. And then
attached to an external pulse generator.
• Procedure done bedside or under fluroscopy.

12. Epicardial pacing

13. Epicardiac pacemakers
• In this case, the wires are attached to the
endocardium, and are brought out
through a surgical incision in the thorax.
• These wires are connected to an external
pulse generator.
• Commonly seen after cardiac surgery.

14. Transcutaneous pacing

15. TRANSCUTANEOUS PACING:
• Non- invasive, multifunctional, electrode pads are
placed.
• Placement: anterior- posteriorly, anterior- laterally
• Multifunctional electrode pads are then connected
to an
• External source( defibrillator with pacing ability).
• The external impulse flows through the electrode
pads and subcutaneous skin to the heart.
• Thus pacing the heart.

16. Biventricular pacemakers
• Also known as cardiac resynchronization.
• Used to treat moderate to severe heart failure as a
result of left ventricular dyssynchrony.
• Intraventricular conduction defects result in an
uncordinated contraction of the left and right
ventricle, which causes a wide qrs complex and is
associated with worsening heart failure and
mortality.
• Biventricular pacemakers can incorporate
implantable cardio-verter defibrillators or can be
used alone.

17. Biventricular pacemaker:

18. Parts of a pacemaker device:

20. Pulse generator
• It consists of a circuitry and batteries.
• In a PPI , it is encapsulated in a metal box, embedded under
the skin.
• The box protects the generator from electromagnetic
interference and trauma.
• PPI use lithium batteries. Life span= 8-12 yrs.
• In a TPM, the generator is a small box with dials for
programming. Transcutaneous pacing systems, use external
source like defibrillator with pacing activity.
• TPM use batteries which need replacement as per the use
of the device.
• Transcutaneous systems use rechargeable battery circuitry.

21. Pacemaker lead
• Transmits electrical signal/ current from
the pulse generator to the heart.

22. Pacemaker lead:

23. Types of pacemaker leads
• Single chamber pacemaker:
• 1 lead, either in atrial or ventricular chamber.
• Sensing and pacing functions are confined to
the chamber where the lead is placed.

25. Dual- chamber pacemaker
• 2 leads
• One lead in atrium, other in ventricle.
• Pacing and sensing occur in both heart
chambers, mimicking the physiological pacing.

27. Biventricular pacemaker
• 3 leads- one lead in right atrium, one lead in
right ventricle and one lead in left ventricle

29. Pacemaker codes
• Letter 1: chamber that is paced (A=atria,
V=ventricles, D=dual chamber)
• Letter 2: chamber that is sensed (A=atria,
V=ventricles, D=dual chamber, 0=none)
• Letter 3: response to a sensed event
(T=triggered, I=inhibited, D=dual - T and I,
R=reverse)

30. Pacemaker codes
• Letter 4: rate responsive features; an activity
sensor, e.g. an accelerometer in the pulse
generator, in single or dual chamber
pacemakers detects bodily movement and
increases the pacing rate according to a
programmable algorithm (R=rate responsive
pacemaker).
• Letter 5: Anti-tachycardia facilities.

31. Indications for pacing
• Indications for a temporary pacemaker:
• Emergency/acute:
1)Acute myocardial infarction with:
Asystole
Symptomatic bradycardia
Bilateral bundle branch block
Mobitz type II second degree AV block

32. 2)Bradycardia not associated with acute
myocardial infarction:
Asystole
2nd or 3rd degree AV block
Ventricular tachyarrhythmias

33. 3)Suppression of drug-resistant ventricular
tachyarrhythmia or supraventricular
tachycardia
4)Drug overdose, e.g. digoxin, b-blockers,
verapamil

34. Elective
1)Support for procedures that may promote
bradycardia
• 2)General anaesthesia with:
• 2nd or 3rd degree AV block
• Intermittent AV block
• 1st degree AV block with bifascicular block
• 1st degree AV block and LBBB

35. 3)Cardiac surgery:
• Aortic surgery
• Tricuspid surgery
• Ventricular septal defect closure
• Ostium primum repair

36. Indications for a permanent
pacemaker
• Persisting symptomatic bradycardia
• Complete AV block
• Prevention of atrial fibrillation.
• Dilated cardiomyopathy or hypertrophic
obstructive cardiomyopathy

37. Pacemaker complications
• Failure to output
• Failure to capture
• Oversensing
• Undersensing
• Pacemaker tachycardia
• Pacemaker syndrome
• Twiddler's syndrome

38. Operative failures:
• Pneumothorax
• Pericarditis
• Infection
• Haemothorax
• Air embolism
• Erosion of the pacer through the skin
• Haematomas
• Lead dislodgment
• Venous thrombosis

39. Nursing care
• Continuous ECG monitoring of heart rate &
rhythm.
• Monitor vital signs for every 15 minutes.
• Monitor urine output.
• Observe for the presence of dysarrhythmia.
• Avoid injury .
• Post insertion chest x-ray.
• Monitor signs &symptoms of haemothorax &
pneumothorax.
• Evaluate continuously for evidence of bleeding.

40. • Monitor for evidence of lead migration.
• Auscultate for pericardial friction rub.
• Provide an electrically safe environment.
• Prevent infection.
• Relieve anxiety.

41. Patient education
• Check pulse daily.
• Avoid weight lifting.[>20 lb]
• Avoid shower.
• Avoid lifting hand over shoulder level.
• Wear loose-fitting clothing.
• Avoid trauma to the area.
• Come for regular check up

42. • Avoid close exposure to magnetic force,
radiation, metal detector etc
• Carry all time pacemaker identity card
• All electronic equipments should be grounded
and repaired