2. Objectives
Review basic pacemaker terminology
and function
Discuss diagnosis and management of
pacemaker emergencies
3. Historical Perspective
Electrical cardiac pacing for the
management of brady-arrhythmias was
first described in 1952
Permanent transvenous pacing devices
were first introduced in the early 1960’s
5. Pulse Generator
Lithium-iodine cell is the current
standard battery
Advantages:
Long life – 4 to 10 years
Output voltage decreases gradually with
time making sudden battery failure unlikely
7. Pacemaker Nomenclature
I II III IV V
Chamber
Paced
Chamber
Sensed
Response to
Sensing
Rate Modulation,
Programmability
Anti-
tachycardia
Features
A=Atrium A=Atrium T=Triggered P=Simple P=Pacing
V=Ventricle V=Ventricle I=Inhibited M=Multi-
programmable
S=Shock
D=Dual D=Dual D=Dual R=Rate Adaptive D=Dual
O=None O=None O=None C=Communicating
O=None
8. Lead Systems
Endocardial leads which are inserted
using a subclavian vein approach
Actively fixed to the endocardium using
screws or tines
Unipolar or bipolar leads
9.
10.
11. Electrocardiogram During
Cardiac Pacing
Pacemaker has two main functions:
Sense intrinsic cardiac electrical activity
Electrically stimulate the heart
VVI- senses intrinsic cardiac activity in
the ventricle and when a preset interval
of time with no ventricular activity
occurs it depolarizes the right ventricle
causing ventricular contraction
13. Electrocardiogram
Dual chamber pacer is more complicated
because the pacer has the ability to both
sense and pace either the atrium or the
ventricle
Possible to have only atrial, only ventricular
or both atrial and ventricular pacing
DDD pacer is a common example of this
16. Magnet Placement
The EKG technician should perform a 12 lead
cardiogram and then a rhythm strip with a
magnet over the pacer
Often a very poorly understood concept by
the non-cardiologist
Does not inactivate the pacer as is commonly
believed
Activate a lead switch present in the
pacemaker which converts the pacer to a
asynchronous or fixed-rate pacing mode
Inhibits the sensing function of a pacemaker
17.
18. Class I Indications For
Permanent Pacing
Third degree AV block associated with:
Symptomatic bradycardia
Symptomatic bradycardia secondary to
drugs required for dysrhythmia
management
Asystole > 3 seconds or escape rate < 40
After catheter ablation of the AV node
Post-op AV block not expected to resolve
Neuromuscular disease with AV block
19. Indications
Symptomatic bradycardia from second
degree AV block
Bifascicular or trifascicular block with
intermittent third degree or type II second
degree block
Sinus node dysfunction with symptomatic
bradycardia
Recurrent syncope caused by carotid sinus
stimulation
20. Indications
Post myocardial infarction with any of:
Persistent second degree AV block with
bilateral bundle branch block or third
degree AV block
Transient second or third degree AV block
and bundle branch block
Symptomatic, persistent second or third
degree AV block
21. Infections
Pacemaker insertion is a surgical
procedure:
1% risk for bacteremia
2% risk for wound or pocket infection
Usually occur soon after pacer insertion
Presence of a foreign body complicates
management
22. Infection
Cellulitis or pocket infection:
Tenderness and redness over the pacemaker
itself
Avoid performing a needle aspiration – damage
the pacer
Bacteremia: Staphylococcus
aureus and Staphylococcus epi 60-70% of the
time
Empiric antibiotics should include vancomycin
pending culture
23. Infection
Consult the pacemaker physician
Draw blood cultures
Give appropriate antibiotics
Frequently the pacer and lead system
need to be removed
24. Case 1
67 year old male presents to the
emergency room 12 hours after
insertion of a pacemaker complaining
of left sided chest pain and shortness of
breath
PR96, RR 33, BP 125/85, Oxygen
saturation 88% RA
CXR as shown
25.
26. Pneumothorax
Occurs during cannulation of the
subclavian vien
Incidence - ?? Cardiologist dependent
Treatment:
Asymptomatic or small – observation
Symptomatic or large – tube thoracostomy
Notify the pacemaker physician
27. Case 2
72 year old male presents to the
emergency room after a fall, tripped
over a bath mat, no LOC
Shortened and rotated left leg
Past history – pacemaker, hypertension
Nurse does an routine pre-op CXR and
EKG
28.
29.
30. Septal Perforation
Usually identified at the time of pacer
insertion but leads can displace after
insertion
Can occur with transvenous pacer
insertion
Keys diagnosis are a RBBB pattern on
EKG and a pacer lead displaced to the
apex of the heart on CXR
31. Septal Perforation
Management:
Notify the pacer service
Pacer wire has to be removed but not
emergently
Small VSD which heals spontaneously
32. Conclusions
Pacemakers are becoming more common
everyday
We need to understand basic pacing
terminology and modes to treat patients
effectively.
Most pacer malfunctions are due to failure to
sense, failure to capture, over-sensing, or in-
appropriate rate
Standard ACLS protocols apply to all
unstable patients with pacemakers.
