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DNURS 835 Basic and Advanced Principles of Nurse Anesthesia 3 > Pacemakers > Flashcards

Pacemakers Flashcards

1
Q

a pacemaker consists of a ___ generator and pacing ___ that deliver electrical current to the heart

A

Pulse generator and pacing leads

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2
Q

Position 1 pacemaker

A

chamber paced

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3
Q

position 2 pacemaker

A

chamber sensed

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4
Q

position 3 pacemaker

A

response to sensed native cardiac activity

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5
Q

position 4 pacemaker

A

programability options

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6
Q

position 5 pacemaker

A

indicates the pacemaker can pace multiple sites

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7
Q

circuit board (“hybrid”)

A

The pulse generator processes electrical info from the heart, and it responds to these signals based on the programmed settings

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8
Q

Where is the atrial lead positioned?

A

lodges in the right atrial appendage

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9
Q

Where is the ventricular lead positioned?

A

lodges in the apex of the right ventricle

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10
Q

What are the indications for pacemaker insertion?

A

SA node disease
AV node disease
Long QT syndrome
Dilated cardiomyopathy
Hypertrophic obstructive cardiomyopathy

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11
Q

What is the mnemonic that can be memorized to remember the 5 letter code of pacemakers?

A

PaSeR

Pa= chamber PAced

Se= chamber SEnsed

R= Response

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12
Q

pacemaker position 1 codes

A

O= none
A= atrium
V= ventricle
D= dual (A+V)

Chamber that is paced

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13
Q

pacemaker position 2 codes

A

O= none
A= Atrium
V= ventricle
D= dual (A+V)

chamber that is sensed

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14
Q

pacemaker position 3 codes

A

O= none

T= triggered (sensed activity tells the pacemaker TO fire

I= inhibited (sensed activity tells the pacemaker NOT to fire)

D= dual (T+I) (if native activity is sensed, then pacing is inhibited, if native activity is not sensed, then the pacemaker fires)

  • Example: a sensed intrinsic atrial beat will inhibit atrial pacing output and will trigger ventricular pacing
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15
Q

pacemaker position 4 codes

A

O= none
R= rate modulation

This indicates the programmability of the pacemaker. This describes the ability to adjust heart rate in response to physiologic needs. Sensors can measure respiration, acid-base status vibration ect.

(will increase the pacer’s lower heart rate limit in response to activity that may require an increased myocardial oxygen demand)

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16
Q

pacemaker position 5 codes

A

O= none
A= atrium
V= ventricle
D= dual (A+V)

This indicates that the pacemaker can pace multiple sites

(pacer may pace BOTH atria and/or BOTH ventricles)

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17
Q

What will you see ok the EKG with atrial pacing?

A

A pacing spike preceded the P wave, QRS is normal

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18
Q

What will you see ok the EKG with ventricular pacing?

A

A pacing spike precedes the QRS complex. The QRS is wide

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19
Q

What will you see ok the EKG with atrial + ventricular pacing?

A

There’s a pacing spike that stimulates the atria and another that stimulates the ventricles.

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20
Q

Examples of Asynchronous pacing

A

AOO
VOO
DOO

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21
Q

examples of single-chamber demand pacing

A

AAI
VVI

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22
Q

examples of dual-chamber AV sequential demand pacing

A

DDD

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23
Q

What does the pacer do in asynchronous pacing?

A

The pacemaker delivers a constant rate

There is no sense or inhibition

There can be a competitive underlying rhythm

A pacer spike delivered during ventricular Repolarization can result on R on T

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24
Q

What does the pacer do in Single-chamber demand pacing?

A

Think of this as a backup mode- it only fires when the native heart rate falls below a predetermined rate

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25
What does the pacer do in a dual chamber AV sequential demand pacing?
The most flexible and most common Makes sure the atrium contracts first, followed by the ventricle This improves AV synchrony
26
Failure to capture:
when the pacemaker’s electrical output fails to cause myocardial depolarization On the EKG you'll see pacing spikes but they aren't followed by a QRS complex (ventricular depolarization)
27
Failure to sense:
the pacemaker fails to recognize intrinsic cardiac electrical activity
28
Indications for ICD
Ventricular tachycardia Ventricular fibrillation Post MI with an EF <30% Cardiomyopathy with an EF <35% Hypertrophic cardiomyopathy Awaiting a heart transplant Long QT syndrome
29
A patient undergoing bunionectomy has a VOO pacemaker with a rate of 80 bpm. During the procedure, there is failure to capture and the heart rate decreases to 50 bpm. Which of the following best explains why this complication occurred A.) the EtCO2 was 20 mmHg B.) an ultrasonic harmonic scalpel was used C.) the patient was hyperthermic D.) the electrocautery setting was changed from coagulation to cutting
A.) the EtCO2 was 20 mmHg The pacemaker failed to capture bc hypocarbia (which caused hypokalemia) made the myocardium more resistant to depolarization. The same electrical stimulus from the pacemaker was no longer sufficient to depolarize the heart. You'll see pacer spikes but will not see capture.
30
What does placing a magnet over a pacemaker do?
(Usually) converts the pacemaker to asynchronous mode
31
What does placing a magnet over a ICD do?
Suspends the ICD and prevents shock delivered
32
What does placing a magnet over a pacemaker + ICD do?
Suspends the ICD and prevents shock delivery. It has no effects on the pacemaker function. Pacemaker function will be subject to EMI. If EMI is likely, then the pacemaker should be reprogrammed by the manufacturer before the surgical procedure
33
What conditions can impair pacemaker performance?
EMI (electromagnetic interference) conditions that make the myocardium more resistant to depolarization: hyper/hypokalemia Hypocapnia hypothermia
34
If surgical electrocautery is used, the best option for the surgeon to use a ______ device
bipolar device
35
T/F: MRI is typically contraindicated for a pt with a pacemaker or ICD
TRUE (some newer devices may be compatible)
36
The most critical information to have preoperatively about a pt with a pacemaker:
The pt's underlying rhythm - so you know how to prepare for device failure
37
How is pacemaker failure treated?
Isoproterenol Epinephrine Atropine (all depending on underlying rhythm)
38
When does failure to sense (undersensing) happen?
When the pacemaker does not sense the underlying (native cardiac rhythm) you will see pacing spikes in areas you would not expect to see them can cause R on T if pacer fires during ventricular repolarization V.fib can happen with ventricular spike lands on T wave
39
Causes of failure to capture:
electrode displacement Wire fracture Conditions that make the myocardium more resistant to depolarization: -hyper/hyperkalemia -hypocapnia (intracellular K+ shift) -Hypothermia -myocardial infarction -Fibrotic tissue buildup around the pacing leads -antiarrhythmic medications
40
Failure to output
Occurs when a pacing stimulus is not produced in a situation when it should be.
41
What can cause failure to output?
oversensing pulse generation failure lead failure
42
When is the risk of EMI greatest?
use of electrocautery and radio frequency ablation
43
Does the coagulation or cutting setting cause on electrocautery cause more EMI?
Coagulation setting causes more use cutting
44
What causes more EMI? A.) monopolar B.) Bipolar C.) ultrasonic harmonic scalpel
Monopolar causes more
45
If the surgeon insists on monopolar cautery, then you insist that they use short bursts
<0.5 seconds
46
The risk of EMI is highest when the electrocautery tip is used within:
a 15 cm radius of the pulse generator
47
Place the electrocautery return pad _____ away from the pulse generator and in a location that prevents a ______ line of current through the pulse generator
Far away direct line
48
Select the interventions that are NOT contraindications with a pacemaker or ICD A. MRI B. Lithotripsy C. electroconvulsive therapy
NOT contraindicated: B. Lithotripsy C. electroconvulsive therapy Contraindicated: A. MRI
49
ICD position 1 codes
SHOCK CHAMBERS O= none A= Atrium V= ventricle D= dual
50
ICD position 2 codes:
ANTI-TACHYCARDIA PACING CHAMBERS: O= none A= atrium V= ventricle D= dual
51
ICD position 3 codes:
TACHYCARDIA DETECTION E= electrocardiogram H= hemodynamic
52
ICD position 4 codes:
ANTI-BRADYCARDIA PACING CHAMBERS O= none A= atrium V= ventricle D= dual
53
An ICD cardioverts V tach with:
1-30 joules
54
and ICD defibs V.fib with
10-30 joules
55
If an ICD acknowledges that a shock is needed, it will deliver how many shocks?
6 shocks
56
EMI:
Any external non-physiologic signal that interferes with pacemaker function o Degree of EMI interference is variable o Inhibition of pacemaker function, inappropriate triggering, electrical reset, damage at tissue -lead interference, tracking of electrical noises are all possible responses
57
What is the most prevalent source of electromagnetic interference in the OR?
electrocautery
58
monopolar cautery produces more energy than bipolar and requires a:
grounding pad
59
Distance between the electrocautery tip and grounding pad will determine:
The area in which a stray current can be sensed and misinterpreted
60
grounding pad should be placed near:
the site of surgery/ away from heart/pacemaker
61
Why is bipolar cautery safer?
has the anode and cathode at the tip of the device, this proximity gives less area for a stray interface to be misinterpreted o does not require grounding pad, gives off less energy, not generally a surgeon’s preference
62
Effects of EMI
-Interpreted as serious dysrhythmia -viewed as “noise” and initiate asynchronous pacing, leading to R on T -Current conducted down lead and damage myocardium -Decrease battery life -Reset device to alternate rate -Be interpreted as P wave causing device to only pace the ventricle, possibly losing atrial kick -Reprogram and alter device setting -Alter thresholds
63
“Magnet rate”
- typically 85-100 beats per minute
64
If a magnet was used intraoperatively, what must be done post-operatively?
a device interrogation must occur postoperatively
65
How much is each horizontal small box?
.04 seconds
66
how much is each horizontal large box?
.20 secs
67
how much is one small box vertically?
1mm (0.1mV)
68
what is the J-point?
end of QRS and beginning of ST segment
69
what is the J-point used to identify/measure?
use the J point with the ST segment to identify myocardial ischemia
70
threshold values for ST segment depression in males and females of all ages in leads V2-V3
-0.5mm (-0.05mV)
71
threshold values for ST segment depression in males and females of all ages in all other leads
-1.0 mm (-0.1 mV)
72
best leads for continuous monitoring of ST segment changes:
V3 V4 V5 III avF
73
best leads for continuous monitoring of ST segment changes:
V3 V4 V5 III avF
74
what is the best lead to assess narrow QRS complex rhythms?
Lead II
75
Which lead is best to assess ST segment changes?
V5 and V3
76
H's
Hypovolemia Hypoxia Hydrogen ion excess (acidosis) Hypoglycemia Hypokalemia Hyperkalemia Hypothermia
77
T's
Tension pneumothorax Tamponade – Cardiac Toxins Thrombosis (pulmonary embolus) Thrombosis (myocardial infarction)
78
V.fib/pulseless Vtach ACLS intervention
CPR 2 mins shock CPR 2 mins Epi 1mg Q3-5 mins shock CPR 2 mins Amiodarone 1st dose: 300mg Amiodarone 2nd dose: 150mg
79
Asystole/PEA ACLS
CPR 2 mins Epi 1mg every 3-5 mins
80
Bradycardia ACLS
Atropine first dose: 1mg (repeat 3-5 mins) max: 3mg transcutaneous pacing dopamine infusion (5-20mcg/kg/min) Epi infusion (2-10mcg/per)
81
when will you see torsades?
Seen with hypokalemia, hypocalcemia, hypomagnesemia May be worsened with lidocaine administration
82
whats the rate of torsades?
150-250bpm
83
if the pt has a pulse and v.tach how would you treat it?
synchronized cardioversion
84
When is a. fib considered "controlled"?
Rate less than 100
85
T/F: you can measure the PR interval in a.flutter
FALSE
86
How long is the PR interval in first degree heart block?
>.20 secs
87
What are the characteristics of second degree block-mobitz 1 (wenkeback)?
Atrial rhythm is regular, but the ventricular rhythm is irregular PR progressively lengths until QRS complex is dropped
88
what are the characteristics of second degree AV block- mobitz II?
p-waves are normal, but some are not followed by QRS PR intervals are constant- the dropped QRS occurs w/o warning
89
What is the rate in 3rd degree?
Less than 45 Pacer is needed
90
What is the rate in Sinus tach?
100-160
91
Males > 40 years of age J-point elevation in all leads
1 mm (0.1mV)
92
Males > 40 V2, V3 J-point elevation
2 mm (0.2mV)
93
females in all leads J-point elevation
> 1mm (0.1mV)
94
females V2, V3 J-point elevation
1.5 mm (0.15mV)

DNURS 835 Basic and Advanced Principles of Nurse Anesthesia 3 (9 decks)

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