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EKG > Pacemakers > Flashcards

Pacemakers Flashcards

1
Q

Failure to Pace/fire problem

A

Pacemaker is not firing (no spike) when it should be!

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2
Q

Signs and symptoms of failure to pace

A

a. No apparent pacemaker activity on ECG
b. Bradycardia
c. Hypotension

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3
Q

Possible causes of failure to pace/fire

A

Think adequate energy is NOT getting from the pacer to the heart

a. mA output set too low on the pacemaker
b. Dead battery in the pacemaker / No battery in the pacemaker
c. Loose connections between the pacing wires and pacing electrodes and the pacemaker itself, or cables incorrectly connected (i.e. ventricular cable/wires in atrial slot)
d. Pacing wire or electrode not in proper contact with the heart – due to malposition, edema, or scar tissue build up at the pacing site
e. Perforation of the heart by the pacing wire/pacing wire is in the wrong place

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4
Q

Other reasons for misdiagnosis for failure to pace/fire

A

a. Undocumented pacing mode change. Check what mode the pacer should be in!
b. Pacing spikes not visible in the present lead. Check other leads for pacing spikes!
c. Pacemaker may be sensing artifact, such as tremors, electrical interference, etc.

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5
Q

Interventions of failure to pace/fire (8)

A
  1. ALWAYS check how your patient is doing first
    a. Check and tighten all connections (if possible)
    b. Increase mA output for increased energy (if possible)
    c. Check other leads for presence of pacer spikes (12 lead ECG if necessary)
    d. Change battery or pacemaker device (if possible)
    e. Change patient position to left side lying (for transvenous pacing wire)
    f. Check all connections and polarity (may reverse positive and negative poles if possible)
    g. Notify physician; have transcutaneous pacemaker present at the bedside
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6
Q

Failure to Capture Problem

A

loss of capture; pacing spike present but no wide QRS following to indicate capture or depolarization of the myocardium. The pacemaker spike is ineffective/useless.

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7
Q

Signs and Symptoms of failure to capture

A

a. Pacemaker spike NOT followed by a wide QRS complex (ventricular pacing) or no P wave (atrial pacing)
b. Bradycardia
c. Hypotension
d. Fatigue

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8
Q

Possible causes of failure to capture

A

Think adequate energy is NOT getting from the pacer to the heart

a. mA output set too low on the pacemaker
b. Dead battery in the pacemaker / No battery in the pacemaker
c. Loose connections between the pacing wires and pacing electrodes and the pacemaker itself, or cables incorrectly connected (i.e. ventricular cable/wires in atrial slot)
d. Pacing wire or electrode not in proper contact with the heart – due to malposition, edema, or scar tissue build up at the pacing site
e. Perforation of the heart by the pacing wire/pacing wire is in the wrong place

a. Metabolic imbalances
b. Physiologic issue changes
c. Drug effects

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9
Q

Interventions of failure to capture (9)

A
  1. ALWAYS check to see how your patient is doing first
    a. Increase mA output on pacemaker when possible
    b. Check and tighten all connections (if possible)
    c. Check all connections and polarity (may reverse positive and negative poles if possible)
    d. Check setting for desired pacing mode
    e. Change battery or pacemaker device (if possible)
    f. Pacing wire or lead may need to be repositioned or replaced
    g. Emergency situation for patients who are pacemaker dependent (relies 100% on the pacemaker for heart beat/contraction)
    h. Notify physician; have transcutaneous pacemaker present at the bedside
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10
Q

Oversensing

A
  1. Problem – results in underpacing. The pacemaker is too sensitive to other signals besides the patient’s natural heart activity. The pacemaker may sense a T wave, skeletal muscle contraction, artifact, or tremors and inappropriately consider it to be the desired native wave it is looking for and does not pace.
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11
Q

Signs and symptoms of oversensing (3)

A

a. Pacemaker paces at rate slower than the set rate
b. Erratic prolongation or shortening of the pacing interval
c. Persistent over-sensing may also appear as a total inhibition of pacing output (failure to pace)

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12
Q

Possible causes of oversensing (4)

A

a. Sensitivity setting is set too sensitive for patient
b. Pacemaker senses artifact such as: skeletal muscle contractions, tremors, or electromagnetic interferences; senses big T waves or senses P waves as a QRS inappropriately and inhibits pacing from occurring
c. Insulation failure or pacing wire fracture
d. Dislodged lead

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13
Q

Interventions of oversensing (5)

A
  1. ALWAYS check how your patient is doing first
    a. Decrease sensitivity – make the pacemaker LESS sensitive to the inappropriate signals
    b. Check patient cables and terminal connections
    c. Resolve electromagnetic interference if possible; decrease artifact signals
    d. May need to replace lead if insulation break or wire fracture is suspected
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14
Q

Undersensing problem

A

Problem: results in overpacing– the pacemaker is not sensitive enough; it does not sense or detect the patient’s own rhythm and continue to pace when it is not needed. Pacer spikes are scattered throughout the ECG rhythm strip with no relationship to atrial or ventricular activity.

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15
Q

Signs and symptoms of undersensing (3)

A

a. Palpitations
b. Skipped beats
c. Competition may cause ventricular tachycardia

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16
Q

Possible causes of undersensing (7)

A

a. Sensitivity setting is not sensitive enough for patient
b. Changes in sensitivity may be caused by edema or fibrosis at/near pacing wire or lead
c. Insulation breaks in pacing lead or a loose connection
d. Pacing lead fracture or displacement
e. Inadequate cardiac signal
f. Battery depletion
g. Incorrect pacemaker mode setting

17
Q

Interventions of undersensing (6)

A

Interventions – ALWAYS check the patient is doing first

a. Increase sensitivity – make the pacemaker MORE sensitive to the patient’s intrinsic rhythm
b. Check terminal connections for loose wire/cables (if possible)
c. Replace battery or external pacemaker device (if possible)
d. May need pacing lead or electrode repositioned
e. May need to replace lead if fracture or displacement is suspected

18
Q

Transcutaneous Pacing

A

Transcutaneous pacing is the initial pacing method of choice in emergent situation because of the speed with which it can be applied. It is the least invasive pacing
technique available. temporary emergent intervention until a more direct means of pacing can be established

19
Q

Indications of Transcutaneous Pacing

A
  1. Hoag’s Emergency Protocol Policy allows a validated RN to initiate TCP for a patient with symptomatic bradycardia and complete heart block.
  2. TCP is preferred in patients who need a pacemaker and may receive thrombolytics, since vascular access is not requires to place TCP electrodes.
20
Q

Technique of Transcutaneous Pacing

A

The key to increasing the effectiveness of TCP is early initiation. Time is crucial; as hypoxia and acidosis increase, the myocardium becomes less responsive.

21
Q

Electrical capture of Transcutaneous Pacing

A

a U-shaped pacer spike before a wide QRS and a broad Twave.

22
Q

Mechanical capture of Transcutaneous Pacing

A

a. A pulse with each electrical complex
b. Adequate blood pressure
c. Improved level of consciousness and skin color, temperature, and moisture

23
Q

Potential complications of Transcutaneous Pacing

A
  1. Unrecognized V-fib
  2. Skin burns caused by high mA, skin sensitivity to adhesive, prolonged pacing
  3. Failure to mechanically capture
24
Q

Hoag’s Emergency Protocol Policy allows a validated RN to initiate TCP for a patient with….

A

symptomatic bradycardia and complete heart block.

25
Q

as hypoxia and acidosis increase…

A

the myocardium becomes less responsive

26
Q

AOO

A

This pacemaker mode paces in the atria 100% of the time; it has NO sensing capability
1. Post-op cardiac surgery in the presence of A-V block, especially after valvular surgery (due to the operative site being close to the AV node and bundle of His)

27
Q

AAI

A

This pacemaker mode paces the atria, senses natural atrial activity, and inhibits pacing if natural activity occurs

  1. Sinus node dysfunction with good AV function (i.e. sinus bradycardia, sinus arrest, sinoatrial block)
  2. Atrial arrhythmias suppressed by chronic atrial pacing (i.e. atrial fibrillation with slow ventricular response)
28
Q

VVI

A

This pacemaker mode paces the ventricle, senses natural ventricular activity, and inhibits pacing if natural ventricular activity occurs

  1. Chronic atrial fibrillation
  2. Iatrogenic heart block with atrial tachyarrhythmia’s
  3. Atrial paralysis
  4. Rare bradycardias
29
Q

DDI

A

This pacemaker mode paces both the atria and ventricle; senses both the atria and ventricle, and inhibits pacing when not needed.

  1. Persistent and profound bradycardia interrupted by episodes of PSVT
  2. Sick sinus syndrome with intact AV conduction
30
Q

DDD

A

This pacemaker can pace both the atria and ventricle, senses both the atria and ventricle, and can both trigger pacing when pacing needed or inhibit pacing when the
patient’s own atria and/or ventricle fire naturally.
1. AV nodal disease with normal sinus function
2. Sinus node dysfunction with poor, questionable AV conduction
3. Atrial arrhythmias suppressed by chronic atrial pacing

EKG (2 decks)

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