Transcript Pacemaker Emergencies - Calgary Emergency Medicine

Pacemaker Emergencies
Arun Abbi MD
Jan 21, 2010
Overview
Initial approach
Pocket Complications
Acute complications with placement
Nonarrythmic complications
Pacemaker function issues
Initial Approach
ABC’s
 - make sure your patient is stable and on a
monitor
Pacemaker 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
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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 falls
PMHx
 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 - ischemia
Check lytes
Refractory V-tach
If wanting to turn off ICD – place magnet
over the ICD
Place defib pads Anterior – Posterior
Shock as per normal