craig hore on emergency pacing

Asystole: a

true story.

Craig Hore

And I don’t mean this one…

Asystole is the end

60 year old man ?previously well Presented to regional hospital ED with

syncope Asystolic arrest soon after arrival Intubated CPR and adrenaline ~ 20 mins Called for senior advice (no ED SS)

“Should we call it?”

“Let me have a quick look…”

Patient is as described ECG rhythm strip:

“Surely we can call it now?”

What would you do?

Clinical examination

Patient looks surprisingly pink for at least 20 mins asystole

Confirm no peripheral pulses but palpable “pulses” with CPR

“Gut feeling” is hmmmm…….

What’s that rule about asystole?

Is it really asystole?

Check other leads (I,III, V) – no obvious difference

Closer look at lead II – are those small bumps?

Rhythm strip with increased amplitude:

“What now then?”

This calls for something completely different….

Wasn’t thinking of this. But…?

Transcutaneous pacing

Transcutaneous pacing

“Older style” TCPM (Lifepak)

Rate set at 70bpm

Amplitude increased by 20 mA increments

Capture at 120 mA

Good pulses and SBP 130mmHg!

Rembrandt van Rijn “The Raising of Lazarus” Los Angeles County Museum of Art, Los Angeles

Rembrandt van Rijn “The Raising of Lazarus” Los Angeles County Museum of Art, Los Angeles

(WTF!)V

The Raising of Lazarus…..

Patient started to move!.....

…opened eyes!!......

..responded to simple instructions!!!

Transcutaneous pacing did not appear to be causing him to much discomfort

What now?

Temporary pacing wire Insertion of temporary transvenous pacing

wire in ED (RIJV; balloon flotation)

Temporary transvenous pacing

How do I know it’s in the correct position?

Length of insertion

ECG electrode

Ectopics

CXR / bedside imaging

Temporary transvenous pacing

What settings?

- demand?

- rate?

- sensitivity?

- output?

Settings Capture threshold - the minimum electricity

output (mA) required to pace the heart (capture)

Asynchronous – paces at a fixed rate, ignoring any of the patient’s intrinsic activity

Demand - paces only if the intrinsic heart rate gets lower than the set rate. This is the usual setting.

Sensitivity – the sensitivity of the pacemaker to the patient’s intrinsic activity. When an intrinsic beat is “sensed’ (sensing light), this “inhibits” the pacemaker from firing

Settings

Setting sensitivity – turn the output to 0 (prevent discharge); set rate below intrinsic rate; reduce sensitivity (increase amplitude) until no sensing of intrinsic activity (sensing threshold); set at ~ half the amplitude of this threshold.

Setting output – turn output to 0 and set rate at 10-15 bpm higher than intrinsic rate; increase output until capture occurs (capture threshold); set at 2-3 times higher than this threshold.

Eventual outcome

Extubated inED Admitted to CICU History of syncope over several months –

neurological work-up was normal! Probable sick sinus syndrome Referred to Metropolitan hospital for

permanent pacemaker Full neurological recovery and return to usual

independent activities

Summary

Don’t ignore those gut instincts

The old rule of thumb: a rhythm disturbance with haemodynamic compromise needs electricity

Temporary pacing can save lives

Transcutaneous pacing is getting better and easier

Temporary transvenous pacemaker insertion is getting better and easier

GiottoThe Arena Chapel Frescoes: The Raising of Lazarus

GiottoThe Arena Chapel Frescoes: The Raising of Lazarus

“It’s a miracle!! The Haematologist was right!”