emergency pacing pearls - physio-control inc., minneapolis, mn december 2007 cable to device...

Emergency Pacing Pearls

Mike McEvoy, PhD, NRP, RN, CCRNCardiac Surgical ICU RN & Chair Resuscitation

Committee – Albany Medical CenterEMS Coordinator – Saratoga County, NY

www.mikemcevoy.com

OutlineWhy pace?

How to pace–Transcutaneous

–Transvenous

What could possiblygo wrong?

Transport considerations

Have You Ever Paced A Patient?

A. YesB. NoC. I watched

Yes No

I watched

77%

8%15%

Why Pace?

Symptomatic bradycardia

Overdrive/supress arrhythmias

Others?

2 Kinds of Temporary PacingTransvenous

Transcutaneous*

Balloon-tipped transvenous wire

Insertion SitesInternal Jugular Vein

Subclavian Vein

Femoral Vein

Brachial Vein

External Jugular Vein

TranscutaneousPacing Pads

Conduct through skin

Pad Placement Tips?

Pad Placement Tips?

Have You Ever Paced Transvenously?


Yes No

I watched

25%31%

44%

Transvenous Pacing

Cable Connectors

Connector pins on the lead(s) must be fully inserted in the patient connector block

Observe polarity– Distal = negative

– Proximal = positive

Finger tighten only –no tools!

Medtronic, Inc., Minneapolis, MN December 2007

Cable to Device Connections

Make sure device is OFF

Cable clicks in place


Emergency Connections

Temporary use only -Leads do not lock in place

5388 5392

MedtronicTemporary Pacemakers

Model 5388 Dual Chamber Temporary Pacemaker1. Pace/Sense LEDs2. Lock/Unlock Key3. Lock Indicators4. Rate Dial5. Atrial Output Dial6. Ventricular Output Dial7. Menu Parameter Dial8. Parameter Selection Key9. Menu Selection Key10. Pause Key11. Power On Key12. Power Off Key13. Emergency/Asynchronous

Pacing Key14. Lower Screen15. Ventricular Output Graphics16. Atrial Output Graphics17. Upper Screen18. Rate Graphics19. Setup Indicators20. DDI Indicator21. Low Battery Indicator22. Setup Labels

Model 5392 Dual Chamber Temporary Pacemaker

Off / On Keys

Values at Power-On

Dual Chamber Pace/Sense• RATE 80 ppm• UPPER RATE 110 ppm

Push onceOFFPush twice

ON

Off / On Keys

Values at Power-On

Dual Chamber Pace/Sense• RATE 80 ppm• UPPER RATE 110 ppm

Push onceON

Emergency Key

Emergency Pacing Values

• RATE Current Rate• A OUTPUT MAX• V OUTPUT MAX• PACING ASYNC• NO SENSING!

Use caution when setting thedevice to asynchronous modes.

Always available – Single key press enters Emergency mode

Emergency Key

Emergency Pacing Values

• RATE Current Rate• A OUTPUT MAX• V OUTPUT MAX• PACING ASYNC• NO SENSING!

Use caution when setting thedevice to asynchronous modes.

Always available – Single key press enters Emergency mode

NBG Codes

Chamber(s) PacedA = atriumV = ventricleD = dual (both atrium

and ventricle)

1st LetterChamber(s) SensedA = atriumV = ventricleD = dualO = none

2nd LetterResponse to SensingI = inhibit

(Demand mode)T = triggeredD = dualO = none (Asynch)

3rd Letter

North American Society of Pacing and Electrophysiology NASPE)

British Pacing and Electrophysiology Group (BPEG)

Generic

NBG Codes

Chamber(s) PacedA = atriumV = ventricleD = dual (both atrium

and ventricle)

1st LetterChamber(s) SensedA = atriumV = ventricleD = dualO = none

2nd LetterResponse to SensingI = inhibit

(Demand mode)T = triggeredD = dualO = none (Asynch)

3rd Letter

V V I

Chamber paced

Chamber sensed

Action or response to a sensed event

Temporary Pacing Parameters

Pacing rate (heart rate)

Output/stimulation threshold

Sensitivity

Pacing Rate

Paced Interval

Paced Interval

Output

The output dial regulates the current or movement of electrons

Pulse Width(ms)

Output/Current(ma)

Output Pulse

Output Capture

Depolarization of cardiac musclefollowing an electrical stimulus

Stimulation ThresholdThe minimum output pulse needed

to consistently capture the heart

3 mA 2 mA 1 mA

SensitivityThe degree that the pacing system “sees” or senses signals, controlled by the sensitivity setting which is

graduated in millivolts (mV)

1.25 (mV)

2.5 (mV)

5 (mV)

Sensitivity (mV)

SensitivityThe lower the setting, the more sensitive the pacemaker is to intracardiac signals

More Sensitive

Less Sensitive

Rate and Output AdjustmentsSingle or Dual Chamber Pacing With Only 3 Dials!

Ventricular Output Dial

Atrial Output Dial

Rate DialMax rate 200bpm(for peds)

For Single Chamber pacing, turn OFF Atrial output

Lower Screen Menus

Menu 1: PacingParameters

TranscutaneousSet Rate

Set Output

Have You Ever Transcutanously Paced?


Yes No

I watched

92%

8%0%

Practice

VVI Demand/Inhibited

Pacemaker senses intrinsic depolarization

Paces the heart when the patient’s own rate becomes slower than the pacemaker

Oversensing

Inhibition of the pacemaker by events pacemaker should ignore, e.g. EMI,

T-waves and myopotentials

Oversensing

Possible Causes Corrective Measures•Fractured/dislodged lead •Replace/reposition lead•Environmental interference •Eliminate interference•T-wave oversensing •Sensing test/decrease sensitivity •Faulty cable connections •Check connections

Things to Know Before Transporting a Transvenous Pacer

1. When and why was it inserted?2. What is the underlying rhythm?3. Is the patient hemodynamically dependent

on the pacer? (i.e., unstable?)4. What are the current settings?

– mA (output)– Rate– sensitivity– Mode

The End

15 seconds of pacing provided while changing 9V battery (note: battery polarity is reversible)

Battery Replacement

1 2

12

Make sure the drawer clicks shut34

30 seconds of pacing provided while changing battery (note: battery polarity is reversible)

Battery Replacement

3

Electromagnetic Interference (EMI)

Radiated or conducted energy – either electrical or magnetic – which can interfere with the function of the pacemaker in the Demand mode

(EMI)

2.5 mV

Should havepaced

80

80


Intrinsic Beat Paced Beat

Fusion Beat Pseudofusion Beat

Fusion/Pseudofusion Beats

Intrinsic Beat Paced Beat

Fusion Beat Pseudofusion Beat

emergency pacing pearls - physio-control inc., minneapolis, mn december 2007 cable to device...

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