Download - Temporary Pacemakers
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Temporary Pacemakers
Sue Shepard, RN, BSNElectrophysiology Care
Coordinator
Children’s Hospital San Diego, CA
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Temporary pacemakers Objectives
Explain the situations when temporary pacemakers are indicated.
Describe the principles of pacing. Illustrate normal and abnormal
pacemaker behavior. Discuss the steps to be taken in
troubleshooting a temporary pacemaker.
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Indications for Temporary Pacing
Bradyarrhythmias AV conduction block
Congenital complete heart block (CHB)- normal or abnormal heart structure
L-Transposition (corrected transposition) Bundle of His long; AV node anterior Prone to CHB
Trauma- surgical or other Slow sinus or junctional rhythm Suppression of ectopy Permanent pacer malfunction Drugs, electrolyte imbalances Sick Sinus Syndrome
Secondary to pronounced atrial stretch Old TGA s/p Senning or Mustard procedure
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Indications for Temporary Pacing
Sick Sinus Syndrome
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Principles of Pacing Electrical concepts
Electrical circuit Pacemaker to patient, patient to pacemaker
Current- the flow of electrons in a completed circuit
Measured in milliamperes (mA)
Voltage – a unit of electrical pressure or force causing electrons to move through a circuit
Measured in millivolts (mV)
Impedance- the resistance to the flow of current
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Principles of Pacing Temporary pacing types
Transcutaneous Emergency use with external pacing/defib
unit Transvenous
Emergency use with external pacemaker Epicardial
Wires sutured to right atrium & right ventricle
Atrial wires exit on the right of the sternum
Ventricular wires exit on the left of the sternum
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Principles of Pacing Wiring systems
Unipolar One electrode on the heart (-) Signals return through body fluid and
tissue to the pacemaker (+) Bipolar
Two electrodes on the heart (- & +) Signals return to the ring electrode (+)
above the lead (-) tip
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Principles of Pacing Modes of Pacing
Atrial pacing Intact AV conduction system required
Ventricular pacing Loss of atrial kick Discordant ventricular contractions Sustains cardiac output
Atrial/Ventricular pacing Natural pacing Atrial-ventricular synchrony
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Principles of Pacing 3-letter NBG Pacemaker Code
First letter: Chamber Paced V- Ventricle A- Atrium D- Dual (A & V) O- None
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Principles of Pacing 3-letter NBG Pacemaker Code
Second letter: Chamber Sensed V- Ventricle A- Atrium D- Dual (A & V) O- None
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Principles of Pacing 3-letter NBG Pacemaker Code
Third letter: Sensed Response T- Triggers Pacing I- Inhibits Pacing D- Dual O- None
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Principles of Pacing Commonly used modes:
AAI - atrial demand pacing VVI - ventricular demand pacing DDD – atrial/ventricular demand
pacing, senses & paces both chambers; trigger or inhibit
AOO - atrial asynchronous pacing
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Principles of Pacing Atrial and ventricular output
Milliamperes (mA) Typical atrial mA 5 Typical ventricular mA 8-10
AV Interval Milliseconds (msec)
Time from atrial sense/pace to ventricular pace
Synonymous with “PR” interval Atrial and ventricular sensitivity
Millivolts (mV) Typical atrial: 0.4 mV Typical ventricular: 2.0mV
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Principles of Pacing (cont.) Atrial/ventricular rate
Set at physiologic rate for individual patient AV Interval, upper rate, & PVARP automatically adjust
with set rate changes Upper rate
Automatically adjusts to 30 bpm higher than set rate Prevents pacemaker mediated tachycardia from
unusually high atrial rates Wenckebach-type rhythm results when atrial rates
are sensed faster than the set rate Refractory period
PVARP: Post Ventricular Atrial Refractory Period Time after ventricular sensing/pacing when atrial
events are ignored
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Principles of Pacing Electrical Safety
Microshock Accidental de-wiring
Taping wires Securing pacemaker
Removal of pacing wires Potential myocardial trauma
Bleeding– Pericardial effusion/tamponade– Hemothorax
Ventricular arrhythmias Pacemaker care & cleaning
Batteries Bridging cables Pacemakers
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Pacemaker Medtronic 5388
Dual Chamber (DDD)
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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 P-WAVE OR QRS COMPLEX FOLLOWING IT.
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Normal Pacing Atrial Pacing
Atrial pacing spikes followed by P waves
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Normal Pacing Ventricular pacing
Ventricular pacing spikes followed by wide, bizarre QRS complexes
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Normal Pacing A-V Pacing
Atrial & Ventricular pacing spikes followed by atrial & ventricular complexes
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Normal Pacing DDD mode of pacing
Ventricle paced at atrial rate
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Abnormal Pacing Atrial non-capture
Atrial pacing spikes are not followed by P waves
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Abnormal Pacing Ventricular non-capture
Ventricular pacing spikes are not followed by QRS complexes
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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
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Failure to Capture Solutions
View rhythm in different leads Change electrodes Check connections Increase pacer output (↑mA) Change battery, cables, pacer Reverse polarity
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Reversing polarity Changing polarity
Requires bipolar wiring system Reverses current flow Switch wires at pacing wire/bridging
cable interface Skin “ground” wire
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Abnormal Pacing Atrial undersensing
Atrial pacing spikes occur regardless of P waves
Pacemaker is not “seeing” intrinsic activity
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Abnormal Pacing Ventricular undersensing
Ventricular pacing spikes occur regardless of QRS complexes
Pacemaker is not “seeing” intrinsic activity
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Failure to Sense Causes
Pacemaker not sensitive enough to patient’s intrinsic electrical activity (mV)
Insufficient myocardial voltage Dislodged, loose, fibrotic, or fractured
electrode Electrolyte abnormalities Low battery Malfunction of pacemaker or bridging
cable
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Failure to Sense Danger – potential (low) for paced
ventricular beat to land on T wave
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Failure to Sense Solution
View rhythm in different leads Change electrodes Check connections Increase pacemaker’s sensitivity (↓mV) Change cables, battery, pacemaker Reverse polarity Check electrolytes Unipolar pacing with subcutaneous “ground
wire”
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Oversensing Pacing does not occur when intrinsic
rhythm is inadequate
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Oversensing Causes
Pacemaker inhibited due to sensing of “P” waves & “QRS” complexes that do not exist
Pacemaker too sensitive Possible wire fracture, loose contact Pacemaker failure
Danger - heart block, asystole
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Oversensing Solution
View rhythm in different leads Change electrodes Check connections Decrease pacemaker sensitivity (↑mV) Change cables, battery, pacemaker Reverse polarity Check electrolytes Unipolar pacing with subcutaneous “ground
wire”
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Competition Assessment
Pacemaker & patient’s intrinsic rate are similar Unrelated pacer spikes to P wave, QRS complex Fusion beats
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Competition Causes
Asynchronous pacing Failure to sense Mechanical failure: wires, bridging cables,
pacemaker Loose connections
Danger Impaired cardiac output Potential (low) for paced ventricular beat to
land on T wave
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Competition Solution
Assess underlying rhythm Slowly turn pacer rate down
Troubleshoot as for failure to sense Increase pacemaker sensitivity (↓mV) Increase pacemaker rate
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Assessing Underlying Rhythm
Carefully assess underlying rhythm Right way: slowly decrease pacemaker
rate
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Assessing Underlying Rhythm Assessing Underlying Rhythm
Wrong way: pause pacer or unplug cables
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Wenckebach Assessment
Appears similar to 2nd degree heart block Occurs with intrinsic tachycardia
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Wenckebach Causes
DDD mode safety feature Prevents rapid ventricular pacing
impulse in response to rapid atrial rate
Sinus tachycardia Atrial fibrillation, flutter Prevents pacer-mediated tachycardia Upper rate limit may be inappropriate
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Wenckebach Solution
Treat cause of tachycardia Fever: Cooling Atrial tachycardia: Anti-arrhythmic Pain: Analgesic Hypovolemia: Fluid bolus
Adjust pacemaker upper rate limit as appropriate
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Threshold testing Stimulation threshold
Definition: Minimum current necessary to capture & stimulate the heart
Testing Set pacer rate 10 ppm faster than patient’s HR Decrease mA until capture is lost Increase output until capture is regained
(threshold capture) Output setting to be 2x’s threshold capture
– Example: Set output at 10mA if capture was regained at 5mA
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Performing an AEG Purpose: Determine existence &
location of P waves Direct EKG from atrial pacing wires
Bedside EKG from monitor Full EKG
Atrial pacing pins to RA & LA EKG lead-wires
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Interpreting an AEG
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Sensitivity Threshold
Definition: Minimum level of intrinsic electric activity generated by the heart detectable by the pacemaker
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Sensitivity Threshold Testing
Testing Set pacer rate 10 ppm slower than patient’s
HR Increase sensitivity to chamber being tested
to minimum level (0.4mV) Decrease sensitivity of the pacer (↑mV) to
the chamber being tested until pacer stops sensing patient (orange light stops flashing)
Increase sensitivity of the pacer (↓mV) until the pacer senses the patient (orange light begins flashing). This is the threshold for sensitivity.
Set the sensitivity at ½ the threshold value. Example: Set sensitivity at 1mV if the threshold
was 2mV
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Factors Affecting Stimulation Thresholds
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Practice Strip#1
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Practice Strip #2
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Practice Strip #3
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Practice Strip #4
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Practice Strip #5
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Practice Strip #6
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Practice Strip #7
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Practice Strip #8
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Practice Strip #9
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AnswersMode of pacing, rhythm/problem, solution
1. AAI: normal atrial pacing2. Sinus rhythm: no pacing; possible back-up setting AAI,
VVI, DDD3. DDD: failure to sense ventricle; increase ventricular
mA4. VVI: ventricular pacing5. DDD: failure to capture atria or ventricle; increase
atrial & ventricular mA6. DDD: normal atrial & ventricular pacing7. DDD: normal atrial sensing, ventricular pacing8. DDD: failure to capture atria; increase atrial mA9. DDD: oversensing; decrease ventricular sensitivity
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References Conover, M. Understanding Electrocardiography, (6th
Ed.). Mosby Year Book; 1992. Hazinski, M. F. Nursing Care of the Critically Ill Child,
(2nd Ed.). Mosby Year Book; 1992. Heger, J., Niemann, J., Criley, J. M. Cardiology for the
House Officer, (2nd Ed.). Williams and Wilkins; 1987. Intermedics Inc. Guide to DDD Pacing, 1985. Moses, H. W., Schneider, J., Miller, B., Taylor, G. A
Practical Guide to Cardiac Pacing, (3rd Ed.). Boston: Little, Brown, and Co.;
1991. Merva, J. A. Temporary pacemakers. RN. May, 1992.