mmuh reg teaching: pacemakers falls blackouts
DESCRIPTION
slideset from this talk http://emergencymedicineireland.com/2012/08/blackouts-and-syncope/TRANSCRIPT
Pacemakers and their problemsSept 2013
Indications
•Symptomatic heart block•Symptomatic sinus brady•AF with symptomatic brady
Also:•Cardiac Resynchronization Therapy•Defibs
Device =
Mode =
Normal: atria and ventricle paced
Normal: ventricle paced
Who
Car
es?
http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th-september-2013_18.html
http://lifeinthefastlane.com/ecg-library/pacemaker/
http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th-september-2013_18.html
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
Pacemaker mediated tachy [=AVRT]http://lifeinthefastlane.com/ecg-library/pacemaker-malfunction/
Runaway pacemaker
Magnet Mode
Lead Fracture
Falls & BlackoutsApril 2012
Falls and blackouts
Acknowledgements/images•Life in the fast lane•Sonocloud.org•Andy Buck•the wonders of YouTube and Wiki•Amal Mattu
Falls and Blackouts
Blackout/Syncope
Falls
http://www.youtube.com/watch?v=DU_i0ZzIV5U
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
Cardiac
•sudden•palpitations•chest pain•witnessed•? LOC
•? murmur•vital signs (RR!)•cognition•neuro
ECG? Blood Sugar
History Exam
HOCM
HOCM
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
RBBB Brugada Brugada
Orthodromic Antidromic
Normal AF WPW AF
Long QT
•Just use the calculated QTc•>500ms before badness happens
Causes
•Syndrome - rare•Low electrolytes•All the drugs in the world...
CH
ES
S
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.
Falls in the elderly
Serious Benign
•Everything... •Nothing...
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
Found on the floor...
•Rhabdo•Hypothermia•Fractures
If they’re now back to baseline?
PMID: 17200478
Risk Assessment
Timed up and go [>20 secs abnormal]
http://www.youtube.com/watch?v=dsTfqk9ZTiw
As yet...
There is no good, reliable test
•Risk assessment•Gait assessment•Have they fallen in the past year
•Falls clinic/assessment
Driving regulations?
Provoked: