Using External Pacemaker
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Indications and instructions for usage of External Pacemakers for EMS and ED
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Using External Pacemaker
- 1. Transcutaneous PacingTranscutaneous Pacing Veronica Bonales, M.D.Veronica Bonales, M.D. St. Joseph HospitalSt. Joseph Hospital Emergency Medicine PhysicianEmergency Medicine Physician
- 2. Why do we care...?Why do we care...? AHA 2016AHA 2016 OOH - >350K - 12% survivalOOH - >350K - 12% survival IH - 209K - 24.8% survivalIH - 209K - 24.8% survival #1 Cause of death - heart disease#1 Cause of death - heart disease VF, VT, high degree AV BlockVF, VT, high degree AV Block
- 3. Back toBack to the Basicsthe Basics Coronary muscleCoronary muscle cells got the beatcells got the beat
- 4. Cardiac MyocytesCardiac Myocytes Intrinsic rhythmIntrinsic rhythm Not coordinated effortNot coordinated effort
- 5. Back toBack to the Basicsthe Basics Heart’s internalHeart’s internal pacemakerpacemaker
- 6. Heart ConductionHeart Conduction SA nodeSA node AV nodeAV node BOHBOH Purkinje fibersPurkinje fibers
- 9. Back toBack to the Basicsthe Basics Coronary arteryCoronary artery anatomyanatomy
- 12. Right MainRight Main Loss of intrinsicLoss of intrinsic pacemakerpacemaker
- 13. Right Coronary Artery MIRight Coronary Artery MI HypotensionHypotension after NTGafter NTG BradycardiaBradycardia Nausea/vomitingNausea/vomiting HiccoughingHiccoughing Urge to defecateUrge to defecate
- 14. Transcutaneous PacingTranscutaneous Pacing Giving the heart a hand... er... pad...Giving the heart a hand... er... pad...
- 15. IndicationsIndications BradycardiaBradycardia 3rd degree heart block3rd degree heart block Mobitz type II 2nd degree heart blockMobitz type II 2nd degree heart block When hemodynamically unstableWhen hemodynamically unstable Overdrive PacingOverdrive Pacing AsystoleAsystole PediatricPediatric StandbyStandby
- 16. Bradycardia (HR < 50)Bradycardia (HR < 50) Hemodynamic InstabilityHemodynamic Instability Acute AMSAcute AMS Severe Chest PainSevere Chest Pain IschemicIschemic CHFCHF SyncopeSyncope
- 17. 3rd Degree Heart Block3rd Degree Heart Block No conduction through the AV nodeNo conduction through the AV node
- 18. Mobitz II - 2nd DegreeMobitz II - 2nd Degree Heart BlockHeart Block Problem in His-Purkinje SystemProblem in His-Purkinje System
- 19. Overdrive PacingOverdrive Pacing Tachydysrhythmia not responsive to drugTachydysrhythmia not responsive to drug therapy or electrocardioversiontherapy or electrocardioversion Usually only good HR <180Usually only good HR <180 Goal to break re-entry circuitGoal to break re-entry circuit AV node able to take controlAV node able to take control Can cause VFibCan cause VFib
- 21. AsystoleAsystole 2010 AHA recommendations2010 AHA recommendations No - out of hospital cardiac arrestNo - out of hospital cardiac arrest YesYes Conduction system problem, P waves presentConduction system problem, P waves present Drug-induced - Digoxin, Procainamide,Drug-induced - Digoxin, Procainamide, ΒΒ-- blockersblockers Unexpected arrest - anesthesia, surgery, cath,Unexpected arrest - anesthesia, surgery, cath, etcetc Following defibrilliationFollowing defibrilliation
- 22. Pediatric PacingPediatric Pacing #1 cause of bradycardia - hypoxia#1 cause of bradycardia - hypoxia Bradycardia from surgically-induced heart blockBradycardia from surgically-induced heart block Congenital AV blockCongenital AV block Viral MyocarditisViral Myocarditis Bradycardia - toxin, drug overdoseBradycardia - toxin, drug overdose PPM failurePPM failure
- 23. Stand-by PlacementStand-by Placement AMI showing signs of heart blockAMI showing signs of heart block Awaiting cardiac surgeryAwaiting cardiac surgery Awaiting PPM, lead wire change, generatorAwaiting PPM, lead wire change, generator changechange Cardiac cath patientsCardiac cath patients Post cardioversion bradycardiaPost cardioversion bradycardia
- 24. Temporary IndicationsTemporary Indications Situation where permanent pacing not neededSituation where permanent pacing not needed Bradycardia secondary to hypothermiaBradycardia secondary to hypothermia In severe, heart won’t respondIn severe, heart won’t respond PEA from: drug overdose, electrolytePEA from: drug overdose, electrolyte abnormality, toxic exposureabnormality, toxic exposure Trauma affecting cardiac functionTrauma affecting cardiac function
- 26. Temporary IndicationsTemporary Indications When unable to place transvenous pacerWhen unable to place transvenous pacer Non-native Tricuspid valveNon-native Tricuspid valve Potential for bleeding - anticoagulantsPotential for bleeding - anticoagulants Potential for infection - immunocompromisedPotential for infection - immunocompromised
- 27. Transcutaneous PacingTranscutaneous Pacing GoalsGoals Keep patient hemodynamically stableKeep patient hemodynamically stable Until underlying problem resolvedUntil underlying problem resolved Until permanent pacing strategy appliedUntil permanent pacing strategy applied
- 28. How to PaceHow to Pace
- 29. External PacingExternal Pacing Consent/Make patient awareConsent/Make patient aware DrugsDrugs Fentanyl/versedFentanyl/versed Morphine/ativanMorphine/ativan Consider intubationConsider intubation
- 30. MethodsMethods Place padsPlace pads Connect EKG leadsConnect EKG leads Pacemaker to demandPacemaker to demand Pace rate >30bpm above intrinsic rhythmPace rate >30bpm above intrinsic rhythm mA to 70mA to 70 Start and increase mA until capture (max of 120 -Start and increase mA until capture (max of 120 - 130)130) Upon capture, set current 5 - 10 mA aboveUpon capture, set current 5 - 10 mA above thresholdthreshold
- 32. MethodsMethods Place padsPlace pads Connect EKG leadsConnect EKG leads Pacemaker to demandPacemaker to demand Pace rate >30bpm above intrinsic rhythmPace rate >30bpm above intrinsic rhythm mA to 70mA to 70 Start and increase mA until capture (max of 120 -Start and increase mA until capture (max of 120 - 130)130) Upon capture, set current 5 - 10 mA aboveUpon capture, set current 5 - 10 mA above thresholdthreshold
- 34. PacingPacing
- 35. ResultsResults Associated with reduced L ventricular systolicAssociated with reduced L ventricular systolic pressurepressure Lower stroke index 2nd to AV dyssynchronyLower stroke index 2nd to AV dyssynchrony Because of muscle contractions, can provideBecause of muscle contractions, can provide greater COgreater CO
- 36. ComplicationsComplications Failure to paceFailure to pace Failure to captureFailure to capture DiscomfortDiscomfort Skin burns (check q 30 minutes)Skin burns (check q 30 minutes)