Temporary pacemaker

PRESENTER- ANURAG JAISWAL

MODERATOR- DR.SHARAD TANDON

# The temporary pacemaker implantation is a therapeutic procedure that can be necessary when the patient has symptoms of low output syndrome due to irreversible and uncontrolled arrhythmia that do not respond to the medical treatment. # Pacemakers provide electrical stimuli to cause cardiac contraction during periods when intrinsic cardiac electrical activity is inappropriately slow or absent.

# Pacemaker output generally stimulates the cavity of the right atrium and or right ventricle.(endocardial pacing).alternatively,epicardial leads can be implanted surgically onto the hearts surface.

# Pacing systems consist of a pulse generator and pacing leads.

Pulse generators
The pulse generator is internal in permanent pacemakers (subcutaneously or submuscularly) and external in temporary pacing. Can be set to a fixed-rate (asynchronous) or demand (synchronous) mode. In the fixed-rate mode, there is a small risk of producing dangerous dysrhythmias if the impulse coincides with the vulnerable period of the T wave. On demand pacemakers detect spontaneous ventricular activity and the output of the pacemaker is either suppressed or discharged in order to make the impulse fall within the safe period of the QRS complex.

PACING LEADS( ELECTRODES )

Transcutaneous Epicardial Transthoracic Transvenous endocardial

TYPES OF PACEMAKER Unipolar pacemakers:

Pacemaker leads are either unipolar (where a single contact is made with the heart) or bipolar. Unipolar systems (ventricular) are used in cases where AV (atrio-ventricular) conduction is likely to return. When there is normal AV conduction and a SA (sinoatrial) disorder, then the pacing wire is situated in the right atrium.

Dual Chamber Pacemakers

Have pacing electrodes in both the right atrium and the right ventricle. They allow maintenance of the physiological relationship between atrial and ventricular contraction.

Dual-site atrial pacing: Newer pacing systems have 2 atrial leads, one in the right atrial appendage and the other either in the coronary sinus or at the os of the coronary sinus. The ventricular lead is in the right ventricle, either at the apex or at the outflow tract. This system has been proposed as a promising treatment option for prevention of paroxysmal atrial fibrillation.

Biventricular pacemakers: Pacemaker leads are placed in the right atrium, right ventricle and left ventricle.
Useful in the management of patients with heart failure who have evidence of abnormal interventricular conduction (most often evident as left bundle branch block on ECG) which causes deranged ventricular contraction or dyssynchrony.

Pacemaker codesThe North American Society of Pacing and Electrophysiology and the British Pacing and Electrophysiology Group have developed a code to describe various pacing modes. It usually consists of three letters, but some systems use four or five: 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) Letter 4: rate responsive features Letter 5: Anti-tachycardia facilities

Temporary PacemakersTranscutaneous external pacemaker Epicardial pacemaker Transthoracic thoracic pacemaker Transvenous endocardial pacemaker

Indications for a temporary pacemakerEmergency/acute:

#Acute myocardial infarction with:

Asystole Symptomatic bradycardia (sinus bradycardia with hypotension and type I 2nd degree AV block with hypotension not responsive to atropine) Bilateral bundle branch block (alternating BBB or RBBB with alternating LAHB/LPHB) New or indeterminate bifascicular block with first degree AV block Mobitz type II second degree AV block After an anterior MI, a pacemaker may be used to prevent bior tri-fascicular block, second or third degree AV block. A pacemaker is only indicated in an inferior myocardial infarction if these conduction disturbances are present

Bradycardia not associated with acute myocardial infarction:

Asystole 2nd or 3rd degree AV block with haemodynamic compromise or syncope at rest Ventricular tachyarrhythmias secondary to bradycardia Suppression of drug-resistant ventricular tachyarrhythmia or supraventricular tachycardia Drug overdose, e.g. digoxin, b-blockers, verapamil

Elective:
Support for procedures that may promote bradycardia 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 Cardiac surgery : Aortic surgery Tricuspid surgery Ventricular septal defect closure Ostium primum repair Rarely considered for coronary angioplasty (usually to right coronary artery) but may be required for angioplasty-induced bradycardia Temporary application during implantation or exchange of permanent pacemaker.

Insertion
External

- applied emergently at the bedside

Epicardial

- leads are placed by the cardiac surgeon in the operating room

Transthoracic

- Usually attempted emergently, as a last resort, after other temporary pacing methods have failed. Physician inserts a pericardial needle through the subxyphoid area of the thorax into the right ventricle and advances the lead wire through the needle in order to achieve contact with the endocardium
Transvenous

- May be inserted at the bedside, preferably under fluroscopy. Usually inserted into the subclavian or jugular vein, but can be inserted into the antecubital or femoral vein

SettingsRate

Fixed

(Asynchronous) # Stimulus is provided at a preset rate # Rate is set greater than the patients inherent rate to avoid competition
(Synchronous) # Stimulus is provided when the patients heart rate drops below at predetermined rate # Must have adequate sensing

Demand

Sensitivity Threshold

Sensitivity # Set in millivolts (mV) # Allows pacemaker to detect the patients inherent R wave Sense Indicator # Flashes when inherent R wave is detected # Senses if pacing is in the demand mode Threshold # The minimum R wave amplitude needed to be detected by the pulse generator # Once the sensitivity threshold is determined, the sensitivity is set 2-3 times lower

Stimulation Threshold

Output/mA
# Stimulus current is measured in milliamperes (mA)

# Adjusted based on the amount of current needed to elicit myocardial depolarization and contraction

variables - position of electrode; contact with viable myocardial tissue; level of energy delivered through wire; presence of hypoxia, acidosis or electrolyte imbalances; and other medications being used

Pace indicator
# Flashes each time a pacing stimulus is generated # Does not necessarily indicate that a cardiac contraction occurred

Pacing Threshold
# The minimum amount of mAs needed to achieve 100% capture # The output is then doubled

Pacing Modes

Atrial asynchronous pacing - atrial fixed pacing

Impulse initiated via the atria Pathway similar to normal conduction Can be initiated via epicardial atrial leads Can result in competition Used for asystole or symptomatic sinus bradycardia Contraindicated for atrial fibrillation or flutter and for person with conduction delays

Ventricular synchronous pacing - ventricular demand pacing

Impulse is sent to the ventricle when the patients inherent rate drops below the preset rate on the pulse generator No harmony between atria and the ventricle Used as a back up system for sinus bradycardia, heart blocks, atrial fibrillation/atrial flutter with SVR, junctional rhythm

AV sequential asynchronous pacing - dual chambered fixed rate pacing

Impulses sent to atria and ventricle at a predetermined rate and at a predetermined AV interval regardless of patients own rhythm

Normal conduction through the heart Used for asystole, symptomatic sinus bradycardia, and for varying degrees of heart block to maintain AV conduction

AV sequential synchronous pacing - dual chambered demand pacing

Impulses sent to atria and ventricles when the patients rated drops below the preset rate on the pulse generator Normal conduction through the heart Used for asytole, symptomatic sinus bradycardia and heart block

Troubleshooting

Failure to fire - cant see pacemaker spikes during periods of asystole or bradycardia

Loose connections in the pacing system

Failure of pacemaker battery or pulse generator

Fracture of the pacing lead wire Lead wire dislodgement

Failure to capture - pacemaker spike is not followed by a P wave or QRS as appropriate

Loose connections in the pacing system

Increased pacing threshold

Fracture of the pacing lead wire Lead wire dislodgement Failure of pacemaker battery or pulse generator

Undersensing
pacemaker fires with no regard to the patients own rhythm. Dangerous because it may lead to ventricular tachycardia and/or ventricular fibrillation

Inadequate QRS signal Myocardial ischemia, fibrosis, electrolyte imbalances, bundle branch block, or a poorly positioned lead

Oversensing
pacemaker thinks it detects a QRS complex, inhibits itself and doesnt fire

Tall or peaked P waves or T waves

Myopotentials (electrical signals produced by skeletal muscle contraction as with shivering or seizures)

Pacemaker

Medtronic 5388 Dual Chamber (DDD)

Pacemaker EKG Strips

Assessing Paced EKG Strips

Identify intrinsic rhythm and clinical condition Identify pacer spikes Identify activity following pacer spikes Failure to capture Failure to sense

EVERY PACER SPIKE SHOULD HAVE A PWAVE OR QRS COMPLEX FOLLOWING IT.

Normal Pacing

Atrial Pacing

Atrial pacing spikes followed by P waves

Normal Pacing

Ventricular pacing

Ventricular pacing spikes followed by wide, bizarre QRS complexes

Normal Pacing

A-V Pacing

Atrial & Ventricular pacing spikes followed by atrial & ventricular complexes

Normal Pacing

DDD mode of pacing

Ventricle paced at atrial rate

Abnormal Pacing

Atrial non-capture

Atrial pacing spikes are not followed by P waves

Failure to Capture

Causes

Insufficient energy delivered by pacer Low pacemaker battery Dislodged, loose, fibrotic, or fractured electrode Electrolyte abnormalities

Acidosis Hypoxemia Hypokalemia

Danger - poor cardiac output

Failure to Capture

Solutions
View rhythm in different leads Change electrodes Check connections Increase pacer output (mA) Change battery, cables, pacer Reverse polarity

Complications of temporary pacing

Immediate complications # VT , VF # Arterial puncture # Pneumothorax # Brachial plexus injury

Late complications

Ventricular arrhythmias Septicemia Wrong position requiring repositioning

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