1. Pacemakers & Pacing in the ED Albury Wodonga Education Program 2014

2. What’s wrong here? Twiddlers syndrome follow the link to read more Twiddler syndrome Twiddler syndrome

3. Ventricular Electrophysiology Pacemaker cells Myocytes Conduction pathways Ventricular Depolarisation from N Engl J Med 2006;355:288- 94

4. Figure 3. Modulation of cardiac electrical activity by activation of ClC-2 channels in cardiac pacemaker cells and myocytes Changes in action potentials (top panels) and membrane currents (bottom panels) of cardiac pacemaker cells (A), or atrial and ventricular myocytes Duan D J Physiol 2009;587:2163-2177 ©2009 by The Physiological Society Slide showing spontaneous decay of membrane potential causing phase 0 of pacemaker cells Slide showing spontaneous decay of membrane potential causing phase 0 of pacemaker cells note: myocytes also decay but less quickly hence slower intrinsic rates note: myocytes also decay but less quickly hence slower intrinsic rates

5. Why do we need to pace? Sinuatrial pause/arrest Atrial Fibrillation AV block - high degrees which are new Neurally mediated syncope Heart failure - severe cardiomyopathy Cardiac Resynchronisation Therapy -CRT Overdrive pacing

6. Permanent Pacemakers

7. only way of knowing how it operates is by getting the details from the patient can only interrogate the device if you know what type it is

8. Pacing Modes Chamber paced O-none, A-atrial, V-ventricular, D-dual Chamber sensed O-none, A-atrial, V-ventricular, D-dual Response to sensing O-none, T-triggered, I-inhibited, D-dual

9. Magnets and pacemakers All pacemakers respond to a magnet by switching to an asynchronous pacing mode at a programmed atrioventricular (AV) delay and a fixed magnet rate depending on the manufacturer, device model, and the status of the battery. The programmed mode DDD switches to DOO, VVI switches to VOO, and AAI switches to AOO

10. Why pace in ED Bradycardia Sinuatrial disease 3rd degree AV block type 2, second degree block myocardial infarction causing significant AV block

11. Why pace in the ED Profound rhythm disturbance causing haemodynamic compromise Slow rates can be tolerated if BP/GCS normal Failure of chronotropic pharmacotherapies - isoprenaline, adrenaline (atropine is a temporary measure)

12. When do we pace in ED? The decision to institute pacing in the ED should be taken by senior staff or in discussion with a tertiary centre in Melbourne Pacing is not technically difficult The decision to pace is the difficult part

13. How can we pace? TranscutaneousTransvenous

14. Transcutaneous pacing Consent Clean and dry optimise contact Analgesia & Sedation infusions of opiate and benzodiazepine to relieve pain/distress but maintain airway

15. Transcutaneous pacing Mode Fixed or Demand Demand avoids R on T Energy as little as required +10mV Rate60-70bpm enough to maintain haemodynamics

16. Transcutaneous Pacing Confirm Capture ElectricalMechanical check pulse or arterial wave form

17. Tex t Pacing - how to make the Phillips defib. work.

18. Transvenous pacing sterile technique multiple routes best to avoid L sub clavian as this route most commonly used for permanent pacemaker

19. Transvenous pacing Start 25mA - should be able to reduce to 5mA Rate 60-70bpm adjust sensitivity settings to consistently detect native R waves see:sensitivity setting for a recommendation on how to do this sensitivity settingsensitivity setting

20. Transvenous pacing Invasive Less energy required safer for transfer

21. ECG showing atrial pacing

22. How to tell if the pacemaker is also a defibrillator. Shock coils

23. ICD - Internal Cardioverting Defibrillator

24. What can go wrong? Failure to capture HiccupsPainBleedingInfection

25. Links http://lifeinthefastlane.com/education/ccc/pacemakers/ http://lifeinthefastlane.com/education/ccc/temporary- pacemaker-troubleshooting/ http://lifeinthefastlane.com/education/ccc/temporary- pacemaker-troubleshooting/ http://radiopaedia.org/articles/cardiac-pacemakers http://www.cardiacengineering.com/pacemakers-wallace.pdf http://www.modernmedicine.com/modern- medicine/news/temporary-pacemakers http://www.modernmedicine.com/modern- medicine/news/temporary-pacemakers