Cardiac Pacing And ICD

Question 1

Indications for cardiac pacing (emergency)

Answer 1

• Symptomatic or unstable brady
• Severe sick sinus syndrome
• • w asystole and syncope
• Ventricular standstill 2/2 mobits type II AV block
• Torsades- overdrive pacing
• Recurrent monomorphic VT
• • overdrive pacing
• Unstable SVT

Question 2

Access sites for pacing

Answer 2

• Transcutaneous: emergent pacing for unstable brady
• transvenous: urgent use transcutaneous as bridge
• Transesophageal
• epicardial (surgical)
• Permeant (surgical)

Question 3

Pacemaker syndrome

Answer 3

AV syncrony and the presence of ventricular conduction are the MC in setting of VII pacing but also DDI mode

Question 4

Pacemaker malfunction types

Answer 4

Failure to sense (under sensing)
Failure to pace (over sensing)
Failure to capture (wont propigate)
Pacemaker tachycardia
Pacemaker programming error

Question 5

Causes of pacemaker failure to sense

Answer 5

Cant detect due to
- lead placement
- dislodged/broken lead

Program sensing threshold too high

It will go into inhibit mode firing at a set rate regardless of cardiac cycle

Question 6

Cause of pacemaker failure to pace

Answer 6

Electrical interference from:
- skeletal muscle
- smooth muscle myopotentials
- nerve stimulators
- broken pacer leads

Less common - coarse a fib

Leads to brady rhythms cause it isnt firing

Question 7

What causes pacemaker failure to capture

Answer 7

Fires but doesnt initiate propagation
- mechanical - lead issue
- poor cardiac conductivity
- - myocardial disease
- programming problems

May be intermittent

Question 8

Pacemaker associated tachycardia causes

Answer 8

• rapid atrial arrhythmias triggering upper rate response in pt w/ complete heart block
• pacemaker mediated tachycardia
• runaway pacemaker can lead to endless loop tachycardia

Requires interrogation and programming

Question 9

Potential causes of ICD discharge that are inappropriate

Answer 9

• false sensing
• SVT w RVR
• muscle activitity shivering etc
• extraneous - tapping etc
• sensing t waves as QRS (double counting)
• sensing lead fracture or migration
• unstustained tachyarrhythmia
• ICD pacemaker interactions
• component failure

Question 10

ECG changes associated with ICD discharge

Answer 10

Cardiac monitoring is required after discharge
Shock related ST segment elevations or depressions should resolve w/in 15 min, ongoing changes suggest new ischemia

Question 11

Sepsis definition and critieria

Answer 11

D: life-threatenign organ dysfunction caused by dysregulated host response to infection

C: suspected or proven infection and
Increase in SOFA score of 2+ from baseline

Question 12

Septic shock definition and criteria

Answer 12

D: a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality

C: Sepsis and vasopressor therapy required to maintain MAP >65 and lactate >2 despite adequate fluids

Question 13

MC GI manifestation of sepsis?

Answer 13

Ileus

Question 14

Hematologic changes from sepsis

Answer 14

Neutrophilia
Neutropenia
Thrombocytopenia
DIC

Question 15

Frequency of sepsis in ED shock patients?

Answer 15

40%
Sepsis is a clinical diagnosis. Given the high frequency of sepsis in ED patients with undifferentiated shock (40%) think of this cause when uncertain

Question 16

When to use vasopressors in septic shock

Answer 16

Do not delay vasopressors when BP doesnt respond to volume or if overload is suspected

Question 17

pressor choice in septic shock?

Answer 17

1st line Norepinephrine 0.5-30mcg/min

2nd line vasopressin 0.03-0.4mcg/min- to downtitrate norepi

Epi 1-20mcg/min works too but high risk of dosing errors

Question 18

Pressure goals with pressors in septic shock?

Answer 18

MAP >65
SBP >90

Question 19

MC sepsis trigger?

Answer 19

Acute bacterial pneumonia
Mcc agent strep pneumonia, s. Aureus, GN bacillia and legionella pneumonia

Question 20

MC SSTI triggering speis

Answer 20

Cellulitis due to S. Aureus and strep pyogenes

Question 21

Predominent pathogen for sepsis?

Answer 21

Gram positive bacteria

Question 22

Sepsis w/o obvious source?

Answer 22

Concern for bacteremia or endocarditis

Question 23

MC bug for bacteremia:

Answer 23

Outpatient: S. Aureus, S. Pneumonia, Neisseria meningitidis

Question 24

Injection drug users risk of?

Answer 24

Injection drug users: pseudomonas and gram neg bacteremia and endocarditis

Question 25

qSofa criteria

Answer 25

AMS
RR >/= 22
SBP <100

Score >/=2 indicates high risk for poor outcomes

Question 26

Purpose and flaw of qSOFA?

Answer 26

Purpose: rapidly ID high risk pts at presentation

Flaw: misses a lot, if going to admit prob need full SOFA

Question 27

Sepsis critical actions

Answer 27

Pts with severe sepsis and septic shock require the following critical actions between recognition and 3hrs:
- Lactate measuriment
- BC and other cultures
- ABX directed at source or broad
- 30mL/kg fluids
- repeat lactate at 6 hrs (if higher than 2)

Septic shock also requires:
- repeat 20mL/kg bolus
- vasopressors
- reassessment and documentation for tissue perfusion

Question 28

What improves outcomes in sepsis?

Answer 28

Early recognition
Antimicrobials
Volume resuscitation
Assessment of circulation