Pacemaker Emergencies
Arun Abbi MDJan 21, 2010
Overview
Initial approachPocket ComplicationsAcute complications with placementNonarrythmic complicationsPacemaker function issues
Initial Approach
ABC’s - make sure your patient is stable and on a
monitorPacemaker Information
pacemaker type, model, number and manufacturer
Patient will often have a card with the info
Initial Approach
EKG Should be a LBBB pattern for the QRS
Meds Cardiac meds, anti seizure meds (dilantin)
Lytes Check K+,Mg+,Ca+
Initial Approach
If patient is stable and is complaining of palpitations, near syncope, light headedness Get the pacemaker nurse to interrogate the
pacemaker
Pocket Complications
Hematomas Occur after implantation-venous or arterial
bleeder (check for anticoagulation) If the size of your palm - needs surgery
Infection Acute infection - staph aureus Chronic/late infection - staph epidermidis
Case 1
76 yr old male presents with chest pain for 2 days
Pain worse with lying down and better with sitting up
No diaphoresis/orthopnea/SOB Pt had a pacemaker inserted 3 weeks earlier V/S and physical were normal
EKG
Management?
What do you want to do?Any concerns?
Complications with Placement Pneumothorax/hemothorax
Typically present in the first 48 hrs. Treat as most pneumothoraces
DVT Upper extremity DVT’s can occur soon after
placement or in a delayed fashion. Secondary to endothelial disruption
Infection Can get endocarditis (right sided) Can present with chronic infection -
wasting/malaise/thromocytopenia/anemia
Complications with Placement
Acute dislodgement Patient may have an ASD/VSD and pacemaker
lead may migrate across the heart or may migrate into a coronary sinus.
Myocardial Perforation Can present as acute pericarditis Can present with hiccups secondary to
diaphragmatic innervation
Failure to Pace
1.Oversensing Secondary to the pacemaker sensing P or T waves
of muscle fasciculations Careful with succinylcholine
Higher incidence with unipolar sensing (VVI) as the antennae is larger
Treatment - reduce the sensitivity
Oversensing
Oversensing
Failure to Pace
2. Failure to capture When the impulse is insufficient to cause
myocardial depolarization Causes
Lead Fracture Battery failure Pacemaker failure Local inflammatory response post insertion Electrolyte imbalance leading to prolonged Q-T Medications
Case 2.
62 yr old female presents to emergency with increasing lethargy and confusion
Pt has had a few fallsPMHx
Pt has hx of complete heart block and has a VVI pacemaker
EKG
Failure to Pace
Management 1. Make sure pacemaker rate is faster than
intrinsic heart rate (to see if it paces) Will see change in QRS morphology (LBBB)
2. CXR (look for lead fracture) 3. Check Lytes 4. Check Meds
CXR with Lead fracture
Case 3
54 yr old male presents to the ER with palpitations and feeling light headed.
No chest pain/SOB
EKG
Failure to Sense
When the pacemaker fails to detect native cardiac activity Secondary to ischemia, infarct, pvc’s Lead dislodgement/fracture
Failure to Sense
Management CXR Lytes Meds Will need pacemaker interrogated for
malfunction
Pacemaker Mediated Tachycardia 1. Endless Loop Tachycardia
Re-entry dysrhythmia that occurs with dual chamber pacemakers
PVC - initiating factor Retrograde P-waves that are sensed by the atrial
lead - leading to subsequent ventricular paced beat Treatment - apply magnet over the patient’s
pacemaker to break the cycle Have pacemaker nurse reset parameters of
pacemaker
Pacemaker Mediated Tachycardia
Pacemaker Mediated Tachycardia
2. Tracking of Native Atrial Tachyarrythmia Atrial Flutter/Atrial Fib.
Management Cardiovert the patient if < 48 hrs or pt is
therapeutically anticoagulated Slow the ventricular response rate
Pacemaker Syndrome
Loss of A-V synchrony caused by suboptimal pacing modes Atrial Lead failure Single chamber Pacemakers
Treatment Interrogate/correct pacemaker Check for lead # in the atrium
Runaway Pacemaker
When you see rapid tachycardia > 300 beats/minute
True emergency -may lead to VT/VF Due to pacemaker damage Management
Place the magnet over the patient’s pacemaker It will default to asynch mode at a rate of 70
Pacemaker and MI’s Treat as per patient with LBBB
Concordant ST changes > 1mm ST depression > 1mm in the anterior leads V1 - V3 Discordant ST changes > 5 mm in the anterior leads
Can also slow the pacemaker rate down and see what the underlying ST changes are (would need pacemaker nurse to come in
If concerned - refractory pain not amenable to medical Tx - send to the cath lab.
ICD’s
Placed in patient with class IV chf Ventricular arrthymias HOCUM
ICD’s
Pt’s with V-fib ICD will shock immediately and every 5-10 seconds
thereafter After 15 shocks it will time out for 10 - 15minutes
Pt’s with V-tach ICD will try to overdrive pace for 15-20 seconds before
initiating a shock It will give repeated shocks and then time out after 15-
20 shocks to prevent battery fatigue
ICD’s
If the patient has had ICD shocks; the patient should be seen by cardiology/ICD nurse to have the device interrogated
Check EKG - ischemiaCheck lytes
Refractory V-tach
If wanting to turn off ICD – place magnet over the ICD
Place defib pads Anterior – PosteriorShock as per normal