Pacemaker Emergencies

1. Pacemaker Emergencies Arun Abbi MD Jan 21, 2010

2. Overview • Initial approach • Pocket Complications • Acute complications with placement • Nonarrythmic complications • Pacemaker function issues

3. 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

4. Initial Approach • EKG • Should be a LBBB pattern for the QRS • Meds • Cardiac meds, anti seizure meds (dilantin) • Lytes • Check K+,Mg+,Ca+

5. Initial Approach • If patient is stable and is complaining of palpitations, near syncope, light headedness • Get the pacemaker nurse to interrogate the pacemaker

6. 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

7. 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

8. EKG

9. Management? • What do you want to do? • Any concerns?

10. 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

11. 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

12. 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

13. Oversensing

14. Oversensing

15. 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

16. 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

17. EKG

18. 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

19. CXR with Lead fracture

20. Case 3 • 54 yr old male presents to the ER with palpitations and feeling light headed. • No chest pain/SOB

21. EKG

22. Failure to Sense • When the pacemaker fails to detect native cardiac activity • Secondary to ischemia, infarct, pvc’s • Lead dislodgement/fracture

23. Failure to Sense • Management • CXR • Lytes • Meds • Will need pacemaker interrogated for malfunction

24. 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

25. Pacemaker Mediated Tachycardia

26. 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

27. 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

28. 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

29. 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.

30. ICD’s • Placed in patient with • class IV chf • Ventricular arrthymias • HOCUM

31. 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

32. 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

33. Refractory V-tach • If wanting to turn off ICD – place magnet over the ICD • Place defib pads Anterior – Posterior • Shock as per normal