craig hore on emergency pacing
TRANSCRIPT
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Asystole: a
true story.
Craig Hore
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And I don’t mean this one…
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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)
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“Should we call it?”
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“Let me have a quick look…”
Patient is as described ECG rhythm strip:
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“Surely we can call it now?”
What would you do?
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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?
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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:
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“What now then?”
This calls for something completely different….
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Wasn’t thinking of this. But…?
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Transcutaneous pacing
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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!
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Rembrandt van Rijn “The Raising of Lazarus” Los Angeles County Museum of Art, Los Angeles
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Rembrandt van Rijn “The Raising of Lazarus” Los Angeles County Museum of Art, Los Angeles
(WTF!)V
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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?
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Temporary pacing wire Insertion of temporary transvenous pacing
wire in ED (RIJV; balloon flotation)
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Temporary transvenous pacing
How do I know it’s in the correct position?
Length of insertion
ECG electrode
Ectopics
CXR / bedside imaging
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Temporary transvenous pacing
What settings?
- demand?
- rate?
- sensitivity?
- output?
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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
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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.
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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
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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
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GiottoThe Arena Chapel Frescoes: The Raising of Lazarus
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GiottoThe Arena Chapel Frescoes: The Raising of Lazarus
“It’s a miracle!! The Haematologist was right!”