This document discusses emergency issues related to pacemakers and implantable cardioverter defibrillators (ICDs). It covers clinical cases, device components and functions, complications, and emergency department management strategies. Key points include descriptions of pacemaker modes and indications for pacemakers, cardiac resynchronization therapy, and ICDs. Common complications like infection, lead issues, and inappropriate shocks are reviewed. The document stresses the importance of obtaining a history, physical exam, ECG, and device interrogation in the ED. Magnet use and Sgarbossa criteria for diagnosing acute MI in paced patients are also summarized.
Electrical cardiac pacing for the management of bradyarrhythmias
was first described in 1952, and permanent transvenous pacing
devices were introduced into clinical practice in the early 1960s.
Electrical cardiac pacing for the management of bradyarrhythmias
was first described in 1952, and permanent transvenous pacing
devices were introduced into clinical practice in the early 1960s.
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
Fractional Flow Reserve during CAG, Radiofrequency ablation during EP study, Shunt calculation by right heart catheterization, and equation for pulmonary venous resistance
A rapid guide for short-term learning of electrocardiography history and the applications of electrocardiogram in cardiac monitoring and the diagnosis of heart pathologic conditions. Would be useful for the students who want to begin to learn this topic and the healthcare practitioners who need a review.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as âdistorted thinkingâ.
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
Fractional Flow Reserve during CAG, Radiofrequency ablation during EP study, Shunt calculation by right heart catheterization, and equation for pulmonary venous resistance
A rapid guide for short-term learning of electrocardiography history and the applications of electrocardiogram in cardiac monitoring and the diagnosis of heart pathologic conditions. Would be useful for the students who want to begin to learn this topic and the healthcare practitioners who need a review.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as âdistorted thinkingâ.
Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
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Andreas Schleicher presents at the OECD webinar âDigital devices in schools: detrimental distraction or secret to success?â on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus âManaging screen time: How to protect and equip students against distractionâ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective âStudents, digital devices and successâ can be found here - https://oe.cd/il/5yV
Model Attribute Check Company Auto PropertyCeline George
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In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
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This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
Palestine last event orientationfvgnh .pptxRaedMohamed3
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An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
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Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
This is a presentation by Dada Robert in a Your Skill Boost masterclass organised by the Excellence Foundation for South Sudan (EFSS) on Saturday, the 25th and Sunday, the 26th of May 2024.
He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
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The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesarâs dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empireâs birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empireâs society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
7. Pacemaker components and lead position
⢠Basic components: pulse generator and lead(s)
⢠Pulse generator; hard and software, battery (5-10 years)
⢠Leads:conductor, electrode, fixation mechanism, terminal
connector pin, insulator
8. Lead position
⢠Atrial leads in the right atrial appendage
⢠Right atrial septum position to suppress AF
⢠Right ventricular leads are traditionally placed in the right
ventricular apex, however RVOT or inter-ventriculair position to
avoid dyssynchrony
⢠Left ventriculair lead via coronary sinus to free left lateral or
posterior left ventriculair wall
⢠Final position depends on venous cardiac anatomy, avoidance of
phrenic nerve stimulation, location of myocardial scar
12. Pacemaker modes
⢠ED physicians most likely deal with AAIR, VVIR, DDD
and DDDR
⢠Rate response modality detect physiological changes;
minute ventilation, QT interval, stroke volume
13. Indications
⢠Continuous amendments for pacemaker indications
several categories)
⢠Most recent guideline ACC/AHA/HRS guideline
pacemaker, ICD and CRT implantation 2008 (update
2012 on CRT)
14. Pacemaker indication
⢠Sinus node dysfunction;
Symptomatic SSS
DDDR*
⢠Acquired AV block;
- III and Mobitz II degree block
- Dual chamber pacing preferrable
⢠Chronic bifascicualr or trifascicular block
Syncope risk varies based on presence of AV block and
pacemaker indication depends of HV intervals (EP-study)
15. CRT
⢠Systolic heart failure due intra- and inter-ventriculair dyssynchrony
⢠Dyssynchrony occurs independent from QRS duration
⢠Dyssynchrony determined by Echocardiographic parameters; TDI
and speckle tracking imaging
⢠In patients with systolic heart failure significant reduction in NYHA
class*(PATH-HF, MUSTIC SR, MIRACLE, COMPANION,CARe-
HF,MIRACLE-ICD,CONTAK-CD,RHYTHM-ICD)
⢠Non-responders to CRT; 10-40% non LBBB (QRS <130 msec,
RBTB)
18. ICD; indications 2012 ACCF/AHA/HRS guidelines
Level of Evidence: A:
LVEF<35% due to prior MI who are at least 40 days post MI (NYHA II-III)
LV dysfunction due to prior MI, LVEF < 30%, NYHA I
Survivors of Cardiac arrest due to VF or hemodynamically unstable sustained
VT after evaluation to define the cause of event and excluding any reversible
causes
Level B
Non-ischeamic DCM LVEF < 35%, NYHA II-III
Non sustained VT due to prior MI, LVEF < 35% or inducible VF/FT on EPS
Structural heart disease and spontaneous sustained VT
Syncope of undetermined origen with clinically relevant HD sign sustained VT
or VF induced at EPS
LQTS patients who experience syncope and/or VT while on b-Blockers
20. Pocket hematoma
⢠Post procedural bleeding and pocket hematoma are relatively
common complications (on oac)
⢠Hematomaâs are generally treated conservatively unless large or
very painful they need surgical intervention (increased rate of
infection)
21. Infection
⢠About 0.2% (retrospective studie) of surgical site infection
(swelling, dehiscencion, erosion)
⢠However, fever of unknown origin an implanted device should
always be considered as a source of infection
⢠BC, Echogardiographic Dx
⢠Long term IVAB (Stahp A), device removal and lead extraction.
Re-insertion of device contralateral
22. Heamato- and pneumothorax
⢠About 1.5% pneumothorax (subclavian puncture)
⢠Hemothorax due to unintentional arterial puncture
⢠Avoidance with fluoroscopic insertion techniques or axillary
vein cannulation
23. Thrombosis
⢠Subclavian or brachio-chephalic venous thrombosis is a very
common event after pacemaker implantation with an
incidence of 2-22% from several days to up to 9 years after
implantation
⢠Often an asymptomatic occurrence shown on a venogram
during lead revision
⢠Symptomatic patients show typical manifestations of acute
DVT (swelling) or even vena cava superior syndrome
⢠PE is an uncommon event
⢠Therapy ranges from heparinisation/warfarin unto
percutaneous angioplasty or open surgery
24. Pacemaker syndrome
⢠Intolerance to ventricular pacing in the absence of
atrioventricular synchrony (âthe AV dyssynchrony syndromeâ)
⢠Ventricular pacing leads to suboptimal AV dyssynchrony
regardless of the pacing mode
⢠Symptoms result from the loss of physiological timing of atrial
and ventricular contractions
⢠Symptoms are a constellation of features due to decreased
cardiac output, loss of atrial contribution to ventricular filling,
loss of total peripheral resistance response, non physiological
pressure waves
⢠Patient needs adjustment of generator or lead to better
coordinate timing of atrial and ventricular contraction
25. Triscupid regurgitation
⢠Some patients present with R sided cardiac failure
⢠mechanism; impingement or adherence to leaflets,
perforation, impairment of valve closure due to entanglement,
, scar formation of thrombosis
⢠Or due to ventricular dyssynchrony
⢠Dx is made by 3D-TTE
26. Twiddler Syndrome
⢠Lead dislodgement due to a patientâs own compulsive
manipulation of generator causing the leads to become retracted
or coiled around the generator
⢠Dx ismade by radiographic appearance
⢠Dacron pouches
⢠Subpectoral pouches
27. Pacing system malfunction
⢠Generator malfunction in 4.6/1000 pacemakers and 20.7/1000
ICDs, most often due to battery malfunction
⢠Lead failure often due to insulation breaks, however this is a late
complication
⢠Pacemaker malfunction is a rare cause of syncope (8/162
patients in a retrospective study)
⢠An assesment of pacemaker malfunction should consist of ECG,
radiology, patients acid-base status (VBG), medication use and
interrogation (lead problems can result in very high impedance)
28. Lead dislodgement
⢠Usually after recent implantation, however up to 3 months after
implant is possible
⢠Undersensing, failure to capture or change in DFTs
⢠Telemetry, device interrogation
⢠Obtain a CXR in 2 directions (compare with previous CXR)
⢠Malposition near phrenic nerve or diaphragm may cause
hiccougs or muscle twitching
⢠Seldom leads may cause perforation and tamponade (TTE)
29. Pacing system malfunction
1. Failure to capture
2. Failure to sense
3. Failure to pace
4. Electromagnetic interference
30. Failure to capture
⢠Failure to deliver a pacing stimulus without subsequent
depolarisation
⢠Functional failure to capture when myocardial tissue is in
refractionary state
⢠Pathological failure to capture due to numerous conditions;
myocardial disease, electrolyte disturbances (Potassium !), anti-
arrhythmic drugs (Class Ic and QTc lengthening)
⢠Latency; might be confused with failure to capture; obtain a
multichannel recording recording (interrogation)
⢠Lead dislodgement, perforation and fracture, increasing DFT
may all lead to failure to capture
31. Failure to sense
⢠On myocardial depolarisation a signal is send via the lead wire
and filtered by the generator
⢠Undersensing could be caused by a change in morphology or
vector of the depolarisation front
⢠PVC, BBB or VTs may need exceed the sensing threshold
(depending on the programming)
⢠Break in wire insulation or Battery depletion may cause under
sensing
⢠Undersensing immediate after implantation may be caused by
dislodgement or perforation
⢠Again; Class Ic or HYPERKALEMIA
⢠Long blanking and refractory periods of a pacemaker can lead to
relatively or functional undersensing
32. Failure to pace
⢠Failure to deliver a stimulus to the heart
⢠Absence of pacing artefacts on intrinsic rates lower than the lower rate
of the device
⢠Causes; oversensing, partial lead fracture or insulation defects,
crosstalk
⢠Oversensing could be caused by retrograde P waves, t waves,
ventricular EADs or DADs skeletal myo-potentials (pectoralis,
diaphragm, rectus abdomens)
⢠External electromagnetic interference
⢠Blunt trauma to pulse generator, lead fracture, dislodgement or loose
connection
⢠Pacing artefacts may not be visible on 12 lead ECG and give a false
impression of failure to pace
⢠PACs or PVCs on a single telemetry lead can give a false impression of
failure to pace
33. Pacemaker tachycardia
⢠Also known as pacemaker re-entry tachycardia or endless-loop
tachycardia (like other re-entry dysrhythmias, pacemaker is now a part
of the re-entry circuit)
⢠only in patients with dual chamber devices
⢠An intrinsic premature complex is sensed by an atrial lead of the
pacemaker which responds by generating a ventricular impulse. The
ventricular impuls is retrogradely conducted via the AV node to the atria,
now the atrial lead senses the atrial impulse and generates a ventriculair
pulse (completed loop)
⢠This pacemaker re-entry tachycardia will not exceed the programmed
upper rate, however can be significant enough to cause symptoms
⢠Adenosine may not be effective where as magnet therapy will be
⢠NB ! pacemakers atrial sensing tresholds need to be adjusted
⢠NB ! Mode switch can cause the pacemaker to discontinue atrial
tracking when the atrial upper rate is exceeded
37. Hyperkalemia
⢠Widened QRS complex (widened paced complexes)
⢠Severe hyperkalemia causes a sine wave following pacing
artefacts
⢠Elevation of pacing threshold; increased latency, intermittent
capture, or continuous loss of capture, loss of sensing
⢠Latency may be temporarily overcome by increasing the maximum
voltage of output HOWEVER treatment of hyperkaliema is a
priority
38. Acute myocardial infarction
⢠The depolarisation and depolarisation from ventricular paced
rhythms may complicate the diagnosis of acute MI (also in LBBB)
⢠ST and T waves shift in a discordant direction which can mask or
mimic AMI, âappropiate discordanceâ
⢠SERIAL ECGs show dynamic ST-segment changes
⢠3 criteria used to Dx infarction in patients with LBBB are
⢠Concordant ST-elevation> 1 mm (score 5)
⢠Concordant ST-depression>1 mm in V1-V3 (score 3)
⢠Excessively discordant ST elevation > 5 mm (score 2) in leads
with a negative QRS complex
39. New or old LBBB ?
⢠âNEW developed LBBBâ reflects AMI is NOT true ! Recognition goes
back to 1917 !
⢠New LBBB should be either due to a LARGE anterior or
anteroseptal infarction resulting in a large injury OR very focal lesion
just distal from the His bundel
⢠New or old, not always clearly visible in acute settings
⢠Patients with previous LBBB generally have underlying myocardial
or conduction system abnormalities predisposing to a larger risk
(older, hypertension, CHF)
⢠Historical studies do not make a fair differentiation in patients with
(L)BBB and ACS
⢠New studies show that in only 29% of new LBBB; ACS is present*
*Chang et al, Am J Emerg Med, 2009,; 27:916-21
41. Sgarbossa criteria
Criteria A Sgarbossa: (90% specifity): 5 point
Concordant ST-elevation> ANY 1mm in lead with a positive QRS
Criteria B Sgarbossa: (90% specifity): 3 point
Concordant ST- depression > 1 mm in ANY lead from V1-V3
Criteria C Sgarbossa: Excessively ST-elevation > 5mm score 2
(high sensivity, lower specifity, ratio of R vs > 20%)
> 3 points ; 90% specifity for ACS
Criteria from Sgarbossa based on a retrospective review from 17
patients from GUSTO-1
43. ICD trouble shooting
⢠Device and procedural complications (as with pacemakers)
⢠Arrhythmia related complications; inappropriate shocks,
appropriate shocks; ventricular storm and incessant tachycardia,
phantom shocks
⢠pro-arrhythmic effects
⢠Increased DFT (fibrosis, amiodarone),
⢠Heart-failure
⢠Phantom shocks
⢠Emotional and quality of life issues: anxiety, depression, fear for
Icd discharge, negative life style changes; unable to return to
work or to drive, decrease in physical activity
44. Inappropriate shocks in ICD patients
⢠Most often caused by SVTs or non sustained VTs
⢠Other causes; electromagnetic interference, inappropriate
sensing, ICD malfunction (lead fracture)
⢠Most inappropriate shocks are avoided with modern and
adequate ICD programming (high cut-off rates, arrhythmia
discrimination detection)
45. Appropriate shocks in ICD patients
⢠Increasing arrhythmia duration and ATP have diminished
delivered shocks (ATP terminates at least 90% of VTs)
⢠Electrical storm (definition in ICD carriers is 2 or more adequately
delivered shocks < 24 hours);
⢠Amiodarone loading, b Blockers (reduction of effects of sympatic
nerve system) and sometimes proceeding towards sedation. both
electrical storm and incessant VT indicate a worse prognosis due
to the underlying mechanism
46. Pro-arrhythmic effect of ICD
⢠Arrhythmogenic effect of implanted lead; irritation of local
myocardial tissue, fibrosis.
⢠Inserted in a prior scar site may induce reentry
⢠RV pacing causes interventricular and intraventricular
dyssynchrony
⢠ânormalâ bradycardia back up pacing may result in short-long
pacing sequence leading towards induction of VT
⢠Biventriculair pacing reduces SCD however may induce Vt due to
an abnormal sequence of depolarisation and depolarisation fronts
47. Magnet function
⢠Know where the magnet is located in your ED
⢠Know the effects of applying a magnet to a device
⢠Know the difference between a magnet application and
an electrical reset
⢠Most pacemakers and ICDs turn off the sensing mode
when a magnet is applied over the generator
⢠The pacemaker starts to pace in an asynchronous
mode in a fixed rate (Medtronic 65/min reflects EOL)
⢠Rarely a device may be programmed in a âmagnet offâ
setting
48. When to apply a magnet ?
1. To terminate a pacemaker mediated tachycardia
2. Inappropriate sensing (due to electromagnetic interference;
diathermy, MRI)
3. Over sensing due to lead problems
4. Stop ICD ATP or defibrillation shock therapy (backup
bradycardia pacing will still be provided).NB an alert sound will
be initiated when applying a magnet to a medtronic ICD (also on
lead and impedance problems or EOL)
49. ACLS in an ICD patient
⢠ICD and CRT-D patients should have same approach
⢠SHOCKS delivered are of NO risk for the MET-team
⢠If arrhythmia persists after a device defibrillation, attach patient to
anterior-posterior placed leads preferably 8 cm from generator
⢠Consider magnet placing to avoid unintentional device
defibrillation's
⢠Consider; increased DFTs due to ipsilateral pneumothorax
⢠`consider femoral access instead of subclavian due to often
thromboses veins (or in appropiate response of a pacemaker due
to wire interrogation)
50. More ?
go to: Medtronic Academy (for Physicians)
LIFTL Fellowship exam SAQ and SMACC 2014
Amal Mattu
ECG pedia
51. Back to clinical case
81 male
4/7 post dual chamber pacemaker insertion (pAF)
Re-currence of pre implantation dizziness, palpitations and
SOB
CXR: correct lead position
Interrogation: A not sensing, P wave in bipolar, re-programmed
to bipolar, treshold and impedence normal.
Loaded on amiodarone
52. Literature
1. Up to Date; Electrical storm and incessant ventricular tachycardia, Overview of
pacing in heart failure, implantable cardioverter defibrillators;
2. EMP: Managing Pacemaker related Complications and malfunctions in the ED
3. Cardiac Pacing and ICDs; 4th Edition, K.A Ellenbogen
4. A practical guide to cardiac pacing, 5th edition, H.Weston Moss
5. Electrofysiological Testing, 3d edition, R.N Fogoros
6. AHHF/AHA/HRS 2012 Guidelines for device based therapy
7. Medtronic Academy
8. LIFTL
9. Neeland et al, J am Coll Cardiol, 2012; 10;60 (2):96-105. âEvolving
considerations in the management of patients with LBTB and suspected AMI