mmuh reg teaching: pacemakers falls blackouts
DESCRIPTION
slideset from this talk http://emergencymedicineireland.com/2012/08/blackouts-and-syncope/TRANSCRIPT
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Pacemakers and their problemsSept 2013
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Indications
•Symptomatic heart block•Symptomatic sinus brady•AF with symptomatic brady
Also:•Cardiac Resynchronization Therapy•Defibs
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Device =
Mode =
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Normal: atria and ventricle paced
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Normal: ventricle paced
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Who
Car
es?
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http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th-september-2013_18.html
http://lifeinthefastlane.com/ecg-library/pacemaker/
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http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th-september-2013_18.html
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Problems
Early:•Infection•Bleeding•Lead misplacement•Pacemaker syndrome (poor coordination)•thrombosis
Late:•Battery•failure•runaway pacemaker
•Lead Fracture•Skin Erosion•‘Twiddler’s syndrome’•thrombosis (usually chronic and not a problem)
General:•Mis-sensing•Pacemaker mediated tachy
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Pacemaker mediated tachy [=AVRT]http://lifeinthefastlane.com/ecg-library/pacemaker-malfunction/
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Runaway pacemaker
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Magnet Mode
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Lead Fracture
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Falls & BlackoutsApril 2012
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Falls and blackouts
Acknowledgements/images•Life in the fast lane•Sonocloud.org•Andy Buck•the wonders of YouTube and Wiki•Amal Mattu
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Falls and Blackouts
Blackout/Syncope
Falls
http://www.youtube.com/watch?v=DU_i0ZzIV5U
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Blackouts/Syncope
Serious Benign•Cardiac•HOCM•Brugada•ARVH•QT•AS•Arrhythmias...•PE•Aortic•Ectopic•SAH•Seizure•?TIA
•Neurocardiogenic/vasovagal/faint•Meds•Micturition/Cough syncope•Necktie/Shaving syncope
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Cardiac
•sudden•palpitations•chest pain•witnessed•? LOC
•? murmur•vital signs (RR!)•cognition•neuro
ECG? Blood Sugar
History Exam
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HOCM
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HOCM
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Brugada
•Likely common cause of SCD•ICD only treatment•presence of symptoms is important•Quoted 10% mortality a year if untreated (though recent evidence questions this...)
PMID 20100972
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RBBB Brugada Brugada
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Orthodromic Antidromic
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Normal AF WPW AF
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Long QT
•Just use the calculated QTc•>500ms before badness happens
Causes
•Syndrome - rare•Low electrolytes•All the drugs in the world...
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CH
ES
S
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San Fran/CHESS
The rule performed with a sensitivity of 90% (44/49 outcomes; 95% confidence interval [CI] 79% to 96%) and a specificity of 33% (95% CI 32% to 34%).
Rule performance to predict serious outcomes was sensitivity 74% (95% CI 61% to 84%), specificity 57% (95% CI 53% to 61%)
The rule was 98% sensitive (95% confidence interval [CI] 89% to 100%) and 56% specific (95% CI 52% to 60%) to predict these events.
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Falls in the elderly
Serious Benign
•Everything... •Nothing...
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ACS
•Common•Usually with an associated “anginal equivalent” (lethargy, diaphoresis, shortness of breath) •If isolated blackout with no symptoms prior or after then unlikely (quoted <1% pick up rate for trops in syncope)•Difficulty given baseline ECG changes and renal function
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Found on the floor...
•Rhabdo•Hypothermia•Fractures
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If they’re now back to baseline?
PMID: 17200478
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Risk Assessment
Timed up and go [>20 secs abnormal]
http://www.youtube.com/watch?v=dsTfqk9ZTiw
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As yet...
There is no good, reliable test
•Risk assessment•Gait assessment•Have they fallen in the past year
•Falls clinic/assessment
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Driving regulations?
Provoked: