pacemakers & pacing in the ed albury wodonga education program 2014
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Pacemakers & Pacing in the Pacemakers & Pacing in the EDED
Albury Wodonga Education Program 2014Albury Wodonga Education Program 2014
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What’s wrong here?What’s wrong here?
Twiddlers syndromeTwiddlers syndromefollow the link to follow the link to
read moreread moreTwiddler syndromeTwiddler syndrome
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Ventricular Ventricular ElectrophysiologyElectrophysiology
Pacemaker cellsPacemaker cells
MyocytesMyocytes
Conduction pathwaysConduction pathways
Ventricular Depolarisation from N Engl J Med Ventricular Depolarisation from N Engl J Med 2006;355:288-942006;355:288-94
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Figure 3. Modulation of cardiac electrical activity by activation of ClC-2 channels in cardiac Figure 3. Modulation of cardiac electrical activity by activation of ClC-2 channels in cardiac pacemaker cells and myocytes Changes in action potentials (top panels) and membrane currents pacemaker cells and myocytes Changes in action potentials (top panels) and membrane currents
(bottom panels) of cardiac pacemaker cells (A), or atrial and ventricular myocytes(bottom panels) of cardiac pacemaker cells (A), or atrial and ventricular myocytes
Duan D J Physiol 2009;587:2163-2177Duan D J Physiol 2009;587:2163-2177
©2009 by The Physiological Society©2009 by The Physiological Society
• Slide showing spontaneous decay of membrane potential Slide showing spontaneous decay of membrane potential causing phase 0 of pacemaker cellscausing phase 0 of pacemaker cells
• note: myocytes also decay but less quickly hence slower note: myocytes also decay but less quickly hence slower intrinsic ratesintrinsic rates
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Why do we need to Why do we need to pace?pace?
Sinuatrial pause/arrestSinuatrial pause/arrest
Atrial FibrillationAtrial Fibrillation
AV block - high degrees which are newAV block - high degrees which are new
Neurally mediated syncopeNeurally mediated syncope
Heart failure - severe cardiomyopathyHeart failure - severe cardiomyopathy
Cardiac Resynchronisation Therapy -CRTCardiac Resynchronisation Therapy -CRT
Overdrive pacingOverdrive pacing
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Permanent PacemakersPermanent Pacemakers
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Permanent PacemakersPermanent Pacemakers
only way of knowing only way of knowing how it operates is by how it operates is by getting the details getting the details from the patientfrom the patient
can only interrogate can only interrogate the device if you the device if you know what type it isknow what type it is
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Pacing ModesPacing Modes
Chamber pacedChamber paced
OO-none, -none, AA-atrial, -atrial, VV-ventricular, -ventricular, DD-dual-dual
Chamber sensedChamber sensed
OO-none, -none, AA-atrial, -atrial, VV-ventricular, -ventricular, DD-dual-dual
Response to sensingResponse to sensing
OO-none, -none, TT-triggered, -triggered, II-inhibited, -inhibited, DD-dual-dual
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Magnets and Magnets and pacemakerspacemakers
All pacemakers respond to a magnet by All pacemakers respond to a magnet by switching to an asynchronous pacing mode at a switching to an asynchronous pacing mode at a programmed atrioventricular (AV) delay and a programmed atrioventricular (AV) delay and a fixed magnet rate depending on the fixed magnet rate depending on the manufacturer, device model, and the status of manufacturer, device model, and the status of the battery. the battery.
The programmed mode DDD switches to DOO, The programmed mode DDD switches to DOO, VVI switches to VOO, and AAI switches to AOOVVI switches to VOO, and AAI switches to AOO
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Why pace in EDWhy pace in ED
BradycardiaBradycardia
Sinuatrial diseaseSinuatrial disease
3rd degree AV block3rd degree AV block
type 2, second degree blocktype 2, second degree block
myocardial infarction causing significant AV myocardial infarction causing significant AV blockblock
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Why pace in the EDWhy pace in the ED
Profound rhythm disturbance causing Profound rhythm disturbance causing haemodynamic compromisehaemodynamic compromise
Slow rates can be tolerated if BP/GCS normalSlow rates can be tolerated if BP/GCS normal
Failure of chronotropic pharmacotherapies - Failure of chronotropic pharmacotherapies - isoprenaline, adrenaline (atropine is a isoprenaline, adrenaline (atropine is a temporary measure)temporary measure)
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When do we pace in ED?When do we pace in ED?
The decision to institute pacing in the ED The decision to institute pacing in the ED should be taken by senior staff or in discussion should be taken by senior staff or in discussion with a tertiary centre in Melbournewith a tertiary centre in Melbourne
Pacing is not technically difficultPacing is not technically difficult
The decision to pace is the difficult partThe decision to pace is the difficult part
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How can we pace?How can we pace?
TranscutaneousTranscutaneous
TransvenousTransvenous
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Transcutaneous pacingTranscutaneous pacing
ConsentConsent
Clean and dryClean and dry
optimise contactoptimise contact
Analgesia & SedationAnalgesia & Sedation
infusions of opiate infusions of opiate and benzodiazepine to and benzodiazepine to relieve pain/distress relieve pain/distress but maintain airwaybut maintain airway
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Transcutaneous pacingTranscutaneous pacing
ModeMode
Fixed or DemandFixed or Demand
Demand avoids R on TDemand avoids R on T
EnergyEnergy
as little as required +10mVas little as required +10mV
RateRate
60-70bpm60-70bpm
enough to maintain enough to maintain haemodynamicshaemodynamics
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Transcutaneous PacingTranscutaneous Pacing
Confirm CaptureConfirm Capture
ElectricalElectrical
MechanicalMechanical
check pulse or arterial wave formcheck pulse or arterial wave form
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TeTextxt
Pacing - how to make the Phillips defib. Pacing - how to make the Phillips defib. work.work.
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Transvenous pacingTransvenous pacing
sterile techniquesterile technique
multiple routesmultiple routes
best to avoid L sub best to avoid L sub clavian as this clavian as this route most route most commonly used for commonly used for permanent permanent pacemakerpacemaker
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Transvenous pacingTransvenous pacing
Start 25mA - should be Start 25mA - should be able to reduce to 5mAable to reduce to 5mA
Rate 60-70bpmRate 60-70bpm
adjust sensitivity settings adjust sensitivity settings to consistently detect to consistently detect native R wavesnative R waves
see:see:sensitivity settingsensitivity setting for a recommendation for a recommendation on how to do thison how to do this
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Transvenous pacingTransvenous pacing
InvasiveInvasive
Less energy requiredLess energy required
safer for transfersafer for transfer
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ECG showing atrial ECG showing atrial pacingpacing
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How to tell if the How to tell if the pacemaker is also a pacemaker is also a defibrillator.defibrillator.
Shock coilsShock coils
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Shock Shock coilscoils
ICD - Internal Cardioverting ICD - Internal Cardioverting DefibrillatorDefibrillator
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What can go wrong?What can go wrong?
Failure to captureFailure to capture
HiccupsHiccups
PainPain
BleedingBleeding
InfectionInfection
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LinksLinks
http://lifeinthefastlane.com/education/ccc/pacemakerhttp://lifeinthefastlane.com/education/ccc/pacemakers/s/
http://lifeinthefastlane.com/education/ccc/temporary-http://lifeinthefastlane.com/education/ccc/temporary-pacemaker-troubleshooting/pacemaker-troubleshooting/
http://radiopaedia.org/articles/cardiac-pacemakershttp://radiopaedia.org/articles/cardiac-pacemakers
http://www.cardiacengineering.com/pacemakers-wallhttp://www.cardiacengineering.com/pacemakers-wallace.pdface.pdf
http://www.modernmedicine.com/modern-medicine/http://www.modernmedicine.com/modern-medicine/news/temporary-pacemakersnews/temporary-pacemakers